■BfflMBBftU 






Class 
Book. 



"RDM \ 



Copyright U?.. 



3b 



1922. 



CQEffilGHT DEPOSIT. 



MINOK SUKGEKY 



INCLUDING 



BANDAGING 



/BY 

HENRY m WHARTON, M.D. 

r 

CONSULTING SURGEON TO THE PRESBYTERIAN HOSPITAL, CHILDREN'S HOS- 
PITAL, ST. Christopher's hospital, the bryn mawr hospital 

AND GIRARD COLLEGE; FELLOW OF THE AMERICAN 
SURGICAL ASSOCIATION 



NINTH EDITION. THOROUGHLY REVISED WITH 
450 ILLUSTRATIONS 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1922 






Copyright 

LEA & FEBIGER 

1922 



PRINTED IN U. S. A. 



OCT -7 '22 

©C1A686156 



PREFACE TO THE NINTH EDITION. 



In the preparation of this edition the attempt has been 
made to make the book conform strictly to its title. Major 
operative procedures, demanding a large special experience 
in surgery, have been excluded as not properly germane to 
this work. They require a fuller discussion and description 
than could be allotted to them. 

Space has thus been obtained for the presentation of 
recent additions to our resources which are of general utility, 
such as the simpler methods of transfusion of blood, the 
indications and essentials of debridement, the chlorine 
antiseptics and the Dakin-Carrel method of treatment of 
wounds. Increased recognition is given to local anesthesia 
for minor surgery, and the chapter on surgical bacteriology 
and immunology has been modernized. 

Many smaller changes and additions have been made 
throughout, to cover recent improvements in practice, and 
it is hoped that the book will continue to meet with the 
same cordial approval of student and practitioner as the 
previous editions. 

The author wishes gratefully to acknowledge the invaluable 
assistance of Dr. Damon B. PfeifTer, who made many helpful 
suggestions, and who read the proof and supervised the 
passage of the book through the press. 

H. R. W. 

Philadelphia, 1922. 



CONTENTS. 



PART I. 



BANDAGING. 

Bandaging 17 

The Roller Bandage 18 

Dimensions of Bandages 20 

General Rules for Bandaging 21 

Removal of Bandages 22 

Varieties of Bandages 23 

Circular Bandage 23 

Oblique Bandage 23 

Spiral Bandage 23 

Spiral Reversed Bandage 24 

Spica Bandage 26 

Figure-of-eight Bandage 26 

Recurrent Bandage 27 

Compound Bandages 27 

T-bandage 28 

Double T-bandage 30 

Many-tailed Bandages or Slings . . .' . . . .31 

Handkerchief Bandages 34 

The Occipito-frontal Triangle 36 

The Mento-vertico-occipital Cravat 37 

The Bis-axillary Cravat 37 

The Dorso-axillary Cravat 38 

The Compound Dorso-bis-axillary Cravat .... 38 

Triangular Cap or Suspensory of the Breast .... 39 

The Gluteo-femoral Triangle 40 

Gluteo-inguinal Cravat 41 

Bandages of the Head 43 

Barton's Bandage • 43 

Modified Barton's Bandage 43 

Gibson's Bandage 46 

Oblique Bandage of the Angle of the Jaw 47 

Recurrent Bandage of the Head 48 

Transverse Recurrent Bandage of the Head ..... 50 

V-bandage of the Head > 50 

Head-and-neck Bandage 51 

Crossed Bandage of One Eye 52 

Crossed Bandage of Both Eyes 53 

(v) 



vi CONTENTS 

Bandages of the Head — 

Occipito-facial Bandage 54 

Oblique Bandage of the Head 54 

Occipito-frontal Bandage 55 

Bandages of the Upper Extremity 56 

Spiral Bandage of the Finger . 56 

Spiral Reversed Bandage of the Fingers 57 

Gauntlet Bandage 57 

Demi-gauntlet Bandage 58 

Complete Bandage of the Hand 59 

Spica Bandage of the Thumb 60 

Spiral Reversed Bandage of Arm 60 

Spiral Reversed Bandage of Upper Extremity .... 61 

Figure-of-eight Bandage of the Elbow 62 

Spica Bandage of the Shoulder (Ascending) 63 

Spica Bandage of the Shoulder (Descending) ..... 65 

Figure-of-eight Bandage of Neck and Axilla ..... 66 

Velpeau's Bandage 66 

Desault's Bandage 68 

Arm and Chest Bandage 71 

Bandages of the Trunk 73 

Spiral Bandage of the Chest 73 

Anterior Figure-of-eight Bandage of the Chest .... 73 

Posterior Figure-of-eight Bandage of the Chest .... 74 

Suspensory and Compressor Bandage of the Breast ... 75 

Suspensory and Compound Bandage of Both Breasts . . 76 

Bandages of the Lower Extremity 77 

Single Spica Bandage of the Groin (Ascending) .... 77 

Single Spica Bandage of the Groin (Descending) .... 79 

Double Spica Bandage of the Groins 80 

Spica Bandage of Buttock 82 

T-bandage of Perineum 83 

Figure-of-eight Bandage of Knee ........ 83 

Figure-of-eight Bandage of Both Knees ...... 85 

Complete Bandage of the Foot 86 

Spica Bandage of the Foot 86 

Bandage of Foot Covering the Heel (American) .... 87 

Bandage of Foot Not Covering the Heel (French) . . .88 

Bandage of the Heel ..... ...... 89 

Spiral Reversed Bandage of the Lower Extremity ... 89 

Spiral Reversed Bandage of the Thigh 90 

Figure-of-eight Bandage of the Leg 91 

Special Bandages 92 

Spiral Reversed Bandage of the Penis ....... 92 

Bandage of the Perineum 92 

Recurrent Bandage of a Stump 92 

Bandage for Securing the Hands and Feet in the Lithotomy 

Position 94 

Liebreich's Eye Bandage 94 

Borsch's Eye Bandage 95 

Bandages of Scultetus • 95 

Gauze Bandages - 

Flannel Bandage 99 

Black Muslin Bandages 101 



CONTENTS vn 

Special Bandages — 

The Rubber Bandage 101 

Elastic webbing Bandage 103 

Fixed Dressings, or Hardening Bandages 104 

Plaster-of -Paris Dressings 104 

The Bavarian Dressing 112 

Moulded Plastic Splints 113 

Trapping Plaster-of-Paris Bandages 114 

Removal of Plaster-of-Paris from the Hands 114 

Removal of the Plaster-of-Paris Bandage .115 

Use of Plaster-of-Paris Dressings 117 

The Starched Bandage 117 

Silicate of Potassium or Sodium Bandage 118 

The Paraffine Bandage 119 

Moulded Splints . . . 119 

Raw-hide or Leather Splints 119 

Binder's Board or Pasteboard Splints 120 

Porous Felt Splints 121 

Hatter's Felt Splints 121 

Elastic Cotton Bandage 121 



PART II. 

MINOR SURGERY. 

Materials Used in Surgical Dressings 123 

Strapping -.....' 129 

Poultices 131 

Irrigation 134 

Counter-irritation 138 

Bloodletting 145 

Transfusion of Blood 150 

Intravenous Infusion of Saline Solution 157 

Asphyxia or Apnea 162 

Artificial Respiration . . - 164 

Exploring Syringe 172 

The Stomach-tube 172 

The Stomach-pump 173 

Esophageal Bougie 174 

The Rectal Tube 174 

Rectal Bougies 175 

Enemata 175 

Vaccination 176 

Hypodermic Injections 177 

Exploring Needle 182 

Skin Grafting 182 

Bone Transplantation or Bone Grafting .185 

Electrolysis 188 

Galvano-cautery 188 

Faradization 189 



vm CONTENTS 

The Cystoscope 189 

The Urethroscope 191 

The Panelectroscope 191 

Catheterization of Ureter in Males 191 

Estimation of the Functional Capacity of the Kidneys . 192 
Direct Laryngoscopy, Bronchoscopy, Esophagoscopy and Gastros- 

copy 193 

Massage 194 

Application of Hot Air or Baking 195 

Bier's Hyperemia Treatment 196 

Active or Arterial Hyperemia 199 

Skiagraphy, or Employment of the Roentgen Rays . . . .199 

Roentgen-ray or Radium Therapy 202 

Anesthetics 208 

Local Anesthesia 209 

Infiltration or Terminal Anesthesia 214 

Epidural or Sacral Anesthesia 215 

General Anesthesia 218 

Acidosis, or Acid-intoxication 241 

Trusses for Hernia 241 

Catheters and Bougies 244 

Sutures 253 

Ligatures Used in the Treatment of Vascular Growths . . . 270 

Treatment of Hemorrhage 274 

Constitutional Treatment . . .... 275 

Local Treatment 275 

Temporary Control of Arterial Hemorrhage 275 

Permanent Control of Arterial Hemorrhage 282 

Treatment of Venous Hemorrhage 289 

Treatment of Capillary Hemorrhage 291 

Consecutive or Reactionary Hemorrhage 292 

Treatment of Secondary Hemorrhage 292 

Subcutaneous Hemorrhage 292 

Control of Hemorrhage of Special Parts 293 

Treatment of Abscess 298 

Acute Abscess 299 

Tuberculous or Chronic Abscess 300 

Diffuse Suppuration 302 

Sinus and Fistula 302 

Shock 304 

Dressing of Wounds 308 

Incised Wounds 308 

Lacerated Wounds 309 

Contused Wounds 311 

Punctured Wounds 311 

Stab Wounds 312 

Poisoned Wounds 312 

Scalp Wounds 313 

Gunshot Wounds 314 

Blank-cartridge Wounds , . 315 

Powder Burns 323 

Contusions or Bruises " 324 

Sunburn 324 

Brush-burn 324 



CONTENTS ix 

Dressing of Wounds — 

Burns and Scalds 325 

Effects of Cold 332 

Injuries from Electricity 333 

Lightning Stroke 334 

Roentgen-ray Burns 335 

Bed Sores (Decubitus) 336 

Injuries of Joints 337 

Contusion of Joints 337 

Hemarthrosis . . 337 

Sprains of Joints 337 

Wounds of Joints 338 

Sprain-fracture 341 

Strains of Muscles and Fascia 341 

Diseases Complicating Wounds 343 

Septicemia or Sepsis 343 

Pyemia 344 

Sapremia 344 

Erysipelas 345 

Cellulitis 346 

Air Embolus 347 

Fat Embolism 347 

Thrombosis 348 

Embolism 349 

Gangrene 349 

Noma, Gangrenous Stomatitis, Cancrum Oris .... 356 

Tetanus 357 

Removal of Foreign Bodies 362 

Furuncle, or Boil 367 

Carbuncle 367 

Varicose Veins .... . . 370 

Ulcers 371 



PART III. 

ASEPSIS AND ANTISEPSIS. 

Surgical Bacteriology 379 

Immunity 384 

Antitoxins 384 

Phagocytosis and Opsonic Treatment 385 

Bacterial Vaccines 385 

Leukocytosis 386 

Varieties of Bacteria 387 

Putrefactive Bacteria 393 

Protozoa 394 

Theory of Asepsis and Antisepsis in Wound Treatment . . . 394 

Methods of Disinfection or Sterilization . 396 

Agents Employed to Secure Asepsis 399 

Preparation of Materials Used in Aseptic Operations . . 410 
Methods and Dressings Employed to Secure Asepsis in Treat- 
ment of Wounds 421 

Preparation for Aseptic Operation 422 



CONTENTS 



PART IV. 

FRACTURES. 

General Consideration of Fractures 437 

Examination of Fractures 442 

Repair of Fractures 443 

Provisional Dressings of Fractures . . . . • . . . . . . 444 

Transportation of Fractures of the Extremities 445 

Reduction or Setting of Fractures . 446 

Materials and Appliances Used in the Dressing of Fractures . 447 

Operative Treatment of Simple Fractures .451 

Separation of the Epiphyses 452 

Dressing of Special Fractures ...'...• 454 

Fracture of the Nasal Bone 454 

Fracture of the Malar Bone and Zygoma 455 

Fractures of the Upper Jaw 456 

Fractures of the Lower Jaw 457 

Fracture of the Hyoid Bone 459 

Fractures of the Larynx and Trachea 459 

Fractures of the Ribs 460 

Fractures of the Costal Cartilages 461 

Fractures of the Sternum 461 

Fractures of the Pelvis 462 

Fractures of the Sacrum and Coccyx 462 

Fractures of the Vertebrae 463 

Fractures of the Skull . . . . 464 

Fractures of the Clavicle . 465 

Fractures of the Clavicle in Children . . . . . . 470 

Fractures of the Scapula 471 

Fractures of the Humerus 472 

Fractures of the Olecranon Process of the Ulna . . . .482 

Fractures of the Coronoid Process of the Ulna .... 484 

Fracture of the Shaft of the Ulna 484 

Fractures of the Head and Neck of the Radius .... 484 

Fractures of the Ulna and Radius 485 

Incomplete Fractures of the Ulna and Radius . . . .486 

Fracture of the Lower End of the Radius 487 

Reversed Colles' Fracture .492 

Fractures of the Carpal Bones 492 

Fractures of the Metacarpal Bones 492 

Fractures of the Phalanges . . . 493 

Fractures of the Lower Extremity . . . . . . . . 494 

Fractures of the Femur 494 

Fracture of the Shaft of the Femur in Children . . . . 506 

Fracture of the Patella 508 

Rupture of the Quadriceps Extensor Tendon 511 

Fractures of the Tibia 511 

Fractures of the Tibia and Fibula 511 

Fractures of the Fibula 516 

Fractures of the Tarsal Bones 518 

Fractures of the Metatarsal Bones 519 

Fractures of the Phalanges of the Toes . . . .' . . 519 

Compound or Open Fractures . . 519 



CONTENTS XI 

Ununited Fractures 524 

Bone Transplantation in Ununited Fracture 526 

Deformed Union 527 



PART V. 

DISLOCATIONS. 

General Consideration of Dislocations 529 

Special Dislocations 531 

Dislocations of the Vertebrae 531 

Dislocations of the Coccyx 532 

Dislocations of the Lower Jaw 532 

Dislocation of the Hyoid Bone 533 

Dislocations of the Ribs and Costal Cartilages .... 533 

Dislocations of the Sternum 533 

Dislocations of the Pelvis 534 

Dislocations of the Clavicle 534 

Dislocations of the Scapula . 536 

Dislocations of the Shoulder . 536 

Dislocations of the Elbow 541 

Dislocations of the Head of the Radius 543 

Dislocation of the Upper End of the Ulna 544 

Dislocations of the Wrist 544 

Dislocations of the Bones of the Carpus . . . . . . 545 

Dislocations of the Metacarpal Bones 546 

Dislocations of the Fingers . 546 

Dislocations of the Hip 548 

Dislocations of the Patella 554 

Dislocations of the Knee 554 

Dislocations of the Semilunar Cartilages 555 

Dislocations of the Fibula 556 

Dislocations of the Ankle 556 

Dislocations of the Tarsal Bones 557 

Dislocations of the Metatarsal Bones and Phalanges of the 

Toes 558 

Old Dislocations 558 

Compound Dislocations 559 

Complicated Dislocations 559 

Habitual, Pathological and Congenital Dislocations . . 560 



PART VI. 

OPERATIONS. 

Amputations of the Fingers and Metacarpal Bones .... 561 

Amputations of the Fingers . 562 

Amputation of the Finger through the Metacarpo-phalangeal 

Articulation 563 

Amputations of the Metacarpal Bones 564 

Dressing of Amputations of Fingers and Hand . ■ . . . 567 

Amputations of Toes and Metatarsal Bones 567 

Amputations of the Toes 567 

Amputations of the Metatarsal Bones 570 



xii CONTENTS 

Warts or Verruca 571 

Papilloma 571 

Callosity 571 

Clavis or Corns 572 

Sebaceous Cysts or Wen 572 

Paracentesis Thoracis 573 

Paracentesis Abdominalis 573 

Paracentesis Pericardii 574 

Paracentesis Vesicae 575 

Lumbar Puncture 575 

Circumcision 576 

Varicocele 577 

Treatment of Hydrocele 577 

Ingrown Toenail 578 

Paronychia 580 

Felon or Whitlow 580 

Palmar Abscess t ..... . 582 

Tracheotomy . 582 

Laryngotomy 588 

Laryngo-tracheotomy 589 

Intubation of the Larynx 589 



PART VII. 

LIGATION OF ARTERIES. 

Ligation of Special Arteries 599 

Ligation of the Innominate Artery 599 

Ligation of the Subclavian Artery 600 

Ligation of the Vertebral Artery 602 

Ligation of the Inferior Thyroid Artery 602 

Ligation of the Internal Mammary Artery 602 

Ligation of the Common Carotid Artery 603 

Ligation of the External Carotid Artery . * 604 

Ligation of the Internal Carotid Artery 605 

Ligation of the Superior Thyroid Artery 605 

Ligation of the Lingual Artery 605 

Ligation of the Facial Artery 606 

Ligation of the Occipital Artery 606 

Ligation of the Temporal Artery 607 

Ligation of the Axillary Artery 607 

Ligation of the Brachial Artery 609 

Ligation of the Radial Artery . . . 610 

Ligation of the Ulnar Artery 612 

Ligation of the Interosseous Artery 613 

Ligation of the Abdominal Aorta 613 

Ligation of the Common Iliac Artery 614 

Ligation of the Internal Iliac Artery 615 

Ligation of the External Iliac Artery 615 

Ligation of the Gluteal Artery 617 

Ligation of the Sciatic and Internal Pudic Arteries . . . 617 

Ligation of the Femoral Artery 618 

Ligation of the Popliteal Artery 620 

Ligation of the Anterior Tibial Artery 6i'0 

Ligation of the Dorsalis Pedis Artery 622 

Ligation of the Posterior Tibial Artery 622 



PART T. 

BANDAGING 



Bandages. — These constitute one of the most widely 
used and important surgical dressings ; they are employed 
to hold dressings in contact with the surface of the body, 
to make pressure, to hold splints in place in the treatment 
of fractures and dislocations, and to maintain in their 
natural position parts which may have become displaced. 

Bandages may be prepared of various materials, such 
as linen, crinoline, flannel, gauze or cheese-cloth, rubber- 
sheeting, or muslin, bleached or unbleached ; the lat- 
ter material is the most commonly employed, by reason 
of its cheapness ; flannel, from its elasticity, is sometimes 
used, but its employment for bandages is now generally 
limited to its use in dressings for operative work in con- 
nection with the eye and abdomen, and for a primary 
roller in the application of plaster-of- Paris dressings. 

Bandages are either simple, w T hen composed of one piece 
of material, such as the ordinary roller-bandage, or com- 
pound, when prepared of one or more pieces adapted by 
size and shape to particular objects. 

The importance of being familiar with the general 
rules of bandaging and proficient in the application of 
the roller-bandage cannot be overestimated, and both the 
student and the general practitioner will never have cause 
to regret the time occupied in learning to apply neatly 
this form of surgical dressing; 

2 !7 



18 



BANDAGING. 



A well-applied bandage adds to the security of the dress- 
ing and the comfort of the patient, and the method of 
application often secures for the physician the confidence 
both of the patient and of his friends ; while, on the 
other hand, a badly applied bandage is apt to be uncom- 
fortable and insecure, and to meet with their adverse 
criticism. 

The Roller-bandage. — The roller-bandage consists of 
a strip of woven material, prepared from some one of the 
materials previously mentioned, of variable length and 
width according to the portion of the body to which it is 

Fig. 1. 




Bandage-winder. 

to be applied ; this, for ease of application, is rolled into 
a cylindrical form. 

The material commonly employed for the roller-band- 
age is unbleached muslin, although, for special purposes, 
linen, flannel, rubber-sheeting, crinoline, gauze or cheese- 
cloth may be used. It is important that the roller- 
bandage should consist of one piece, free from seams and 
selvage, for if made of a number of pieces sewed together, 
or if it contains creases or selvage, it cannot be so neatly 
applied, and it is not so comfortable to the patient, as it is 
apt to leave creases upon the skin. 



THE ROLLER-BANDAGE. 19 

In preparing the ordinary muslin bandage, the material 
is torn in strips varying in length and width according to 
the part of the body to which it is to be applied, and it is 
then rolled into a cylinder, either by the hand or by a 
machine constructed for the purpose (Fig. 1). 

It is important that every student and practitioner 
should be able to roll a bandage by hand, for in practice 
the medical attendant may at any moment be called upon 
to prepare a bandage, in order to apply a dressing, and the 
art of preparing a bandage is easily acquired by a little 

Fig. 2. 




Rolling a bandage by hand. 

practice. To roll a bandage by hand, the strip of muslin 
should be folded at one extremity several times until a 
small cylinder is formed ; this is then grasped by its ex- 
tremities by the thumb and index finger of the left hand ; 
the free extremity of the strip is then grasped between 
the thumb and index finger of the right hand, and by 
alternate pronation and supination of the right hand the 
cylinder is revolved and the roller is formed ; the firm- 
ness of the roller will depend upon the amount of tension 
which is kept upon the free extremity of the strip during 
the revolution of the cylinder (Fig. 2). A bandage rolled 



20 



BANDAGING. 



in the form of a cylinder is called a single or single-headed 
roller (Fig. 3) ; if rolled from each extremity toward the 
centre, so that two cylinders are formed joined by the 



Fig. 3. 



Fig. 4. 





Single roller. 



Double roller. 



central portion of the strip, the double or double-headed 
roller is formed (Fig. 4). 

Double rollers are not much used, and in practice the 
single roller will be found to be amply sufficient for the 
application of almost all the bandages employed in sur- 
gical dressings. 

The free end of the roller-bandage is called the initial 
extremity ; the end which is enclosed in the centre of the 
cylinder is its terminal extremity ; and the portion between 
the extremities the body; a roller has also two surfaces, 
external and internal. 

Dimensions of Bandages. — Bandages vary in length 
and width according to the purposes for which they are 
employed, and in practice it will be found that a small 
variety of bandages will be amply sufficient for the appli- 
cation of the ordinary surgical dressings. 

The following list, comprising those most frequently 
used, will show their dimensions : 

Bandages one inch wide, three yards in length, for band- 
ages for the hand, fingers, and toes. 



GENERAL RULES FOR BANDAGING. 21 

Bandages two inches wide, six yards in length, for head- 
bandages and for the extremities in children. 

Bandages two and a half inches wide, seven yards in 
length, for bandages of the extremities in adults ; a roller 
of this size is the one most generally used. 

Bandages three inches wide, nine yards in length, for 
bandages of the thigh, groin, and trunk. 

Bandages four inches wide, ten yards in length, for 
bandages of the trunk. 

General Rules for Bandaging. — In applying a roller- 
bandage, the operator should place the external surface of 
the free extremity of the roller upon the part, holding it 
in position with the fingers of the left hand until fixed by 
a few turns of the roller, the cylinder being held in the 
right hand by the thumb aud fingers; for thus as the 
bandage is unwound it rolls into the operator's hand, 
thereby giving him more control of it ; care should also 
be taken that the turns are applied smoothly to the surface, 
and that the pressure exerted by each turn is uniform. 

When a bandage is applied to a limb, the surgeon should 
see that the part is in the position it is to occupy as re- 
gards flexion and extension when the dressing is com- 
pleted, for a bandage applied when the limb is flexed will 
exert too much pressure when the limb is extended, and 
then may, by the pressure it exerts, become a matter of 
discomfort or even of danger to the patient, or if applied 
to an extended limb it will become uncomfortable upon 
flexion. 

My experience has been that, as a rule, those who have 
had little experience with the application of the roller- 
bandage are apt to apply the bandages too tightly, and 
this may lead to disastrous consequences, gangrene of the 
extremities having resulted from the too tight application 
of bandages, especially in the dressing of fractures. Pro- 
fessor Ashhurst, in his clinical teaching, advised students 
to make use of a larger number of turns of a bandage in 
securing fracture-dressings rather than to depend upon a 
few turns too firmly applied — advice which certainly con- 
duces to the safety and comfort of the patient. When the 



22 



BANDAGING. 



bandage has been completed, the terminal extremity should 
be secured by a pin or safety-pin applied transversely 
to the bandage, and if a pin be used its point should be 



Fig. 5. 




Method of removing a bandage. 



buried in the folds of the bandage ; if the bandage be a 
narrow one, the end may be split and the two tails result- 
ing secured around the part by tying. 



Fig. 6. 




Bandage-scissors. 



Removal of Bandages. — In removing a bandage, the 
folds should be carefully gathered up in a loose mass as 



VARIETIES OF BANDAGES. 23 

the bandage is unwound, the mass being transferred rapidly 
from one hand to the other, thus facilitating its removal 
and preventing the part from becoming entangled in its 
loops (Fig. 5). If it is desirable to cut the bandage to 
remove it, the use of scissors made for this purpose will 
be found most satisfactory (Fig. 6). 



VARIETIES OF BANDAGES. 

Circular Bandage. — This bandage consists of a few 
circular turns around a part, each turn covering accurately 
the preceding turn. This variety of bandage may be used 
to retain a dressing to a limited portion of the head, neck, 
or limbs, to make compression upon the veins of the arm 
before performing venesection, or to secure a compress to 
control venous hemorrhage (Fig. 11). 

Oblique Bandage. — In this form of bandage the turns 
are carried obliquely over the part, leaving uncovered 
spaces between the successive turns (Fig. 7). It cannot 

Fig. 7. 




Oblique bandage. 

be applied with much firmness on account of the swelling 
of the uncovered portions of skin between the turns of 
the bandage, and its principal use is for the application of 
temporary dressings, such as wet dressings which may re- 
quire frequent removal. 

Spiral Bandage. — In this bandage the turns are carried 



24 



BANDAGING. 



around the part in a spiral direction, each turn overlap- 
ping a portion of the preceding one, usually one-third or 
one-half; it may be applied as an ascending spiral (Fig. 8) 



Fig. 8. 




Ascending spiral bandage. 



or as a descending spiral (Fig. 9). This bandage may 
be used to cover a part which does not increase rapidly in 
diameter ; for instance, the abdomen, chest, or arm. 



Fig. 9. 




Descending spiral bandage. 

Spiral Reversed Bandage. — This bandage is a spiral 
bandage, but differs from the ordinary spiral bandage in 
having its turns folded back or reversed as it ascends a 
part the diameter of which gradually increases. By its 
use, it is possible to cover by spiral turns a part conical in 
shape, so as to make equable pressure upon all parts of 
the surface. The reverses are made as follows : After 



COMPOUND BANDAGES. 27 

) 
name from the turns being applied so as to form a figure- 
of-eight. This method of application is made use of in 
the Barton's bandage, the bandages of the knee and elbow, 
and many other bandages. 

Fig. 13. 




Recurrent bandage. 

Recurrent Bandage. — This bandage derives its name 
from the fact that the roller after covering a certain part 
of the surface is reflected and brought back to the point 
of starting ; it is then reversed and carried toward the 
opposite point, and this manipulation is continued until 
the part is covered by these recurrent turns, which are 
then secured by a few circular turns (Fig. 13). This is 
the bandage usually employed in the dressing of stumps 
after amputation. 

Compound Bandages. 

These bandages are usually formed of several pieces of 
muslin or other material, sewed or pinned together, and 
are employed to fulfil some special indication in the appli- 
cation of dressings to particular parts of the body. The 
most useful of the compound bandages are the T-bandages 
and the many-tailed bandages. 



28 



BANDAGING. 



T-bandage. — The single T-bandage consists of a hori- 
zontal band to which is attached, about its middle, another 
having a vertical direction ; the horizontal piece should be 
about twice the length of the vertical piece (Fig. 14). The 



Fig. 14. 




Single T-bandage. 



single T-bandage may be used to retain dressings to the 
head, the horizontal piece being passed around the head 
from the occiput to the forehead, the vertical piece being 



Fi«. 15. 




Single T-bandage for chest. 



passed over the head and secured to the horizontal piece, 
the shape and width of the two pieces being varied accord- 
ing to the indications. In applying dressings to the anal 



COMPO UND BAND A GES. 



29 



region or perineum, or in securing a catheter in a perineal 
wound, the single T-bandage will be found most useful. 
In applying a T-bandage for this purpose, the body of the 
bandage is placed over the spine, just above the pelvis, and 
the horizontal portion is tied around the abdomen. The 
free extremity is split into two tails for about two-thirds 
of its length, and is carried over the anal region and 
brought up between the thighs, the terminal strips passing 
one on each side of the scrotum and being secured to the 
horizontal strip in front. The single T-bandage may be 

Fig. 16. 




T-bandage of groin. 

variously modified according to the indications which are 
to be met ; for instance, in applying a dressing to the 
breasts the horizontal strip passing around the chest may 
be made ten or twelve inches in width ; the vertical 
strip, two inches in width, passes from the back over the 
shoulder and is secured to the horizontal strip in front 
(Fig. 15). For the groin, a piece of muslin six inches 



30 



BANDAGING. 



wide at its base and thirty inches long is sewed to a hori- 
zontal strip of muslin one and a half yards long and two 
inches in width. It may be applied as in Fig. 16 to hold 
a dressing to this part. 

Double T -bandage. — The double T-bandage differs 
from the single bandage in having two vertical strips 
attached to the horizontal strip, and it may be used for 
much the same purposes as the single T-bandage (Fig. 17). 



Fig. 17. 




Double T-bandage. 



It may be conveniently used for retaining dressings to the 
chest, breast, or abdomen ; when used for this purpose the 
horizontal portion should be from eight to twelve inches 
wide and long enough to pass one and a quarter times 
about the chest ; two vertical strips, two inches wide and 
twenty inches long, should be attached to the horizontal 
strip a short distance apart near its middle. In applying 
this bandage to the chest, the horizontal strip is placed 
around the chest so that the vertical strips occupy a posi- 
tion on either side of the spine ; the overlapping end of 
the horizontal portion is secured by pins or safety-pins, 
and the vertical strips are next carried one over either 
shoulder and secured to the other portion of the bandage 
in front of the chest (Fig. 18). 

The double T-bandage may also be used to secure dress- 



COMPOUND BANDAGES. 



31 



ings to the nose, in which event the strips should be quite 
narrow, about one inch in width, and should be applied as 
shown in Fig. 1 9. 



Fig. 18. 



Fig. 19. 





Double T-bandage of cbest. 



Double T-bandage of nose. 



Many-tailed Bandages or Slings. — These bandages 
are prepared from pieces of muslin of various lengths and 
breadths, which are split at each extremity into two, three, 
or more tails up to within a few inches of their centres, 
their width and length being regulated by the part of the 
body to which they are to be applied. 

The four-tailed bandage may be found useful as a tem- 
porary dressing in cases of fracture of the jaw, or to hold 
dressings to the chin. It may be prepared by taking a 
portion of a roller-bandage three inches wide and one 
yard in length, and splitting each extremity up to within 
two inches of the centre ; it is then applied as seen in 
Fig. 20. 

The four-tailed bandage may also be used to retail* dress- 
ings to the scalp, and may be prepared by taking a piece of 
muslin one yard and a quarter long and six or eight inches 
in width, splitting it at each extremity into two tails within 
six inches of the centre; it may then be applied as seen 
in Fig. 21. 

The four-tailed bandage may also be used in the tern- 



32 



BANDAGING. 



porary dressing of fractures of the clavicle, the body of 
the bandage being placed upon the elbow of the injured 



Fig. 20. 



Fig. 21. 



•f 




Four-tailed bandage of chin. 



Four-tailed bandage of head. 



side, two tails passing around the body, fixing the arm to 
the side, and two tails passing over the sound shoulder. 



Fig. 22. 




Many-tailed bandage of abdomen. 



Many-tailed Bandage of Abdomen. — This bandage may 
also be used for holding dressings in contact with the abdo- 
men or trunk, and is the bandage which most surgeons 



COMPOUND BANDAGES. 



33 



employ to hold the dressings to a laparotomy wound, and 
to give support to the abdominal walls after this opera- 
ation. In preparing this bandage, a strip of muslin or 

Fig. 23. 




Dressing secured by strips of plaster and safety-pins. 
Fig. 24. 




Dressing for laparatomy wound held by strips of plaster and tapes. 

flannel, one and a half yards in length and eighteen to 
twenty inches in width, is required ; the extremities may 
be split on each side to within six inches of the centre 
so as to form a four- or six-tailed bandage. In applying 
this bandage to the abdomen, the body is placed upon the 
patient's back and the tails are brought around the abdo- 
men and overlap each other, and when sufficiently firmly 
3 



34 



BANDAGING. 



drawn to make the desired amount of pressure they are 
secured by means of safety-pins (Fig. 22). 

Many surgeons prefer to hold the dressings to a lapar- 
otomy wound in place by three or four broad straps of 
adhesive plaster passing from the back across the abdomen. 
These are cut in the centre at the first dressing, and the 
ends turned back to remove the dressings. When the new 
dressing is applied, it is secured in place by holding to- 
gether the cut ends of the straps by safety-pins (Fig. 23). 

When the dressing of a laparotomy wound requires fre- 
quent changing, it will be found convenient to hold the 
dressing in place by straps of adhesive plaster nine inches 
in length and two inches in width. Three or four such 
strips are attached to the back on each side of the abdo- 
men, and to the free end of each strap is attached a short 
piece of tape. When the dressing is applied to the wound, 
the ends of the corresponding tapes are tied together and 
the dressing is secured in place (Fig. 24). 

Handkerchief-bandages . 

The use of handkerchiefs or square pieces of muslin for 
the temporary or permanent dressing of wounds, fract- 
ures, or dislocations was advocated many years ago by M. 

Fig. 26. 







Fig. 25. 






\» 




_______£_„ C=i=g- 


-=-„ 






\Jj! 


" ; J~ - - 


\ J 


i^EEE^Ezl 




=:: — $iii 










|SE-=---=- Sill -=. 


iiii 

















— ill" 


--*■■; ipr 


.!i:si 









i| 


"f 




--=r~ 


==■■ | 


\ if 

lilfx 


1:1 


-Ef:=— ■—■ 






::!.! 


~ - 




i 






lii> 


P-- 


-=_ iji! \ 


'ill 




il 


""iL- 


::™jU----~-. 


-1L 




jjjji 


if'™" 


::~~:: :r |!j — "~r:^™«-==iiif\. 




ijji 


flr- 
jjj 


ill! 

11! 


sjl 


N-j-^-.. 


iiii' 


ii 

IS 


II 












\ 



The square. The oblong. 

Mayor, a Swiss surgeon, who wrote an extensive work 
upon this subject, in which he reduced their application 



HA NDKERCHIEF-BANDA GES. 



35 



to a system. He employed a handkerchief or a square piece 
of muslin, and by various modifications in the application 
of these developed a number of very ingenious bandages. 

The various forms which the handkerchief or square 
(Fig. 25) is made to assume are as follows : The oblong, 



Fig. 27. 




The triangle. 



made by folding the square once or twice on itself (Fig. 
26). The triangle, made by bringing together the diag- 
onal angles of the square (Fig. 27). The line of the fold- 



Fig. 28. 




The cravat. 



ing is known as the base, the angle opposite the base the 
apex, and the other angles the extremities. 

The cravat is prepared from the triangle by bringing the 




apex to its base, and folding it a number of times upon 
itself until the desired width is obtained (Fig. 28). 

The cord is formed from the cravat twisted upon itself 
(Fig. 29). The names of the various handkerchief-band- 
ages are derived from the shape of the handkerchiefs 
used and the parts to which they are applied ; the names 



36 



BANDAGING. 



serve as guides in their application. It is to be remem- 
bered that the base of the triangle or the body of the cravat 
is to be placed upon the portion, the designation of which 
forms the first portion of the name of the bandage ; thus, 
in the occipitofrontal triangle, the shape of the nandker- 
chief is given, and we know that the base of the triangle 
is to be applied to the occiput and the apex carried to the 
forehead. In using the cravats the same rule applies; 
thus, in the bis-axillary cravat the body of the cravat is 
to be placed in the axilla of the affected side, the extremi- 
ties crossed over the corresponding shoulder and carried 
over the chest, one before, the other behind, to the axilla 
of the opposite side, where they are secured. 



Fig. 30. 



Fig. 31. 





Occipitofrontal triangle. 



Mento-vertico-occipital cravat. 



The Occipitofrontal Triangle. — To apply this hand- 
kerchief, place the base of the triangle upon or a little 
below the occiput, and bring the apex forward over the 
head, allowing it to drop over the forehead ; next bring 
the extremities of the handkerchief forward and tie them 
in a knot over the forehead ; finally turn up the apex over 
the knotted ends and pin it to the body of the handker- 
chief (Fig. 30). 






HANDKERCHIEF-BANDA GES. 



37 



The Mento-vertico-occipital Cravat. — To apply this 
handkerchief, the middle of the base of the cravat is placed 
under the chin ; the extremities are then carried in front 
of the ear on each side to the vertex of the skull, and are 
crossed at that point ; the ends are then carried downward 
over the parietal region to the occiput, and are secured by 
a knot at this point (Fig. 31). Another method of apply- 
ing this handkerchief consists in placing the base of the 

Fig. 32. 




Mento-vertico-occipital cravat (modified). 

cravat under the chin and carrying the extremities over 
the vertex of the skull, crossing them at that point ; then 
carrying them downward to the occiput, and crossing them 
again here and passing them forward around the chin, and 
finally securing the ends by a knot (Fig. 32). The turns 
of the latter handkerchief correspond exactly to the turns 
of the Barton's bandage of the head. 

These handkerchief-bandages may be used to secure 
dressings to the chin or scalp, or may be employed as tem- 
porary dressings to secure fixation of the parts in cases of 
fracture or dislocation of the jaw r . 

The Bis-axillary Cravat. — To apply this handker- 
chief, the body of the cravat is placed in the axilla, and 



38 



BANDAGING. 



the ends are brought up, one in front of, the other behind, 
the axilla, and are made to cross over the top of the 
shoulder ; the extremities are then carried across the back 
and chest respectively to the opposite axilla, where they 
are secured by tying (Fig. 33). This handkerchief may 
be employed to secure dressings in the axilla, or to hold 
dressings in contact with the shoulder. 



Fig. 33. 




Bis-axillary cravat. 

The Dorso -axillary Cravat. — This handkerchief is 
applied by placing the body of the cravat over the spine 
between the scapulae, and then carrying one extremity over 
the shoulder and through the axilla backward to meet the 
other extremity, which has been carried through the axilla 
and over the other shoulder to the back, where the ends 
are secured by a knot (Fig. 34). This handkerchief may 
be used to hold dressings to the axilla or upper portion of 
the back of the chest. 

The Compound Dorso-bis-axillary Cravat. — To ap- 
ply this handkerchief, two cravats are required. The base 



HANDKEBCHIEF-BANDA GES. 



39 



of one cravat is placed over the front of one shoulder, and 
the ends are passed, one over the top of the shoulder, the 
other through the axilla, and they are then secured by a 
single knot over the scapula ; the ends are next secured by 
tying them in a loop. The second cravat is next placed 
in front of the shoulder on the opposite side, and the ends 

Fig. 34. 




Dorso-axillary cravat. 

are respectively carried over the shoulder and through the 
axilla to the back, where they are secured by a single knot ; 
the ends of the handkerchief are then passed through the 
loop of the first handkerchief and secured by a knot 
(Fig. 35). This handkerchief may be used to draw the 
shoulders backward in cases of dislocation or fracture of 
the clavicle. 

Triangular Cap or Suspensory of the Breast. — To 
apply this handkerchief, the base of the triangle is placed 
under the affected breast, and one extremitv is carried be- 
neath the axilla of the same side, and the other extremity 
is carried around the opposite side of the neck, and they 



40 



BANDAGING. 



are secured together upon the back by a knot ; the apex 
should then be brought up over the breast and shoulder 
of the affected side, and pinned to the bandage over the 
scapula (Fig. 36). This handkerchief may be employed 
to sling the breast in nursing-women, or to hold a dressing 
to the breast. 

Fig. 35. 




Compound dorso-bis-axillary cravat. 

The Gluteo-femoral Triangle. — In applying this hand- 
kerchief, a cravat is first fastened around the waist, and a 
second handkerchief folded into a triangle has its base 
placed in the gluteo-femoral fold, and its extremities car- 
ried around the thigh and secured in front by a knot; 
the apex of the handkerchief is then carried upward and 
passed beneath the cravat around the waist, and is turned 
down and pinned to the body of the triangle (Fig. 37). 
This handkerchief may be used to retain dressings to the 
region of the buttock or hip ; by unpinning the apex and 
turning it downward, ready access can be had to the parts 
beneath. 



HA ND KERCHIEF-BAND A GES. 



41 



Gluteo-inguinal Cravat. — In applying this handker- 
chief, the base of the cravat is placed just over the gluteo- 
femoral fold, and the extremities are carried forward, one 



Fig. 36. 




^wtf»»~ 




Triangular cap or suspensory of the breast. 

around the inner, the other around the outer portion of 
the thigh, and they are made to cross in the groin ; the 
ends are next passed around the pelvis and secured to- 
gether upon the back by a knot (Fig. 38). This handker- 
chief may be employed to hold dressings to the region of 
the groin. 

By employing two cravats, a double gluteo-inguinal 
cravat may be applied, which may be used to hold dress- 
ings to both groins. The turns of these cravats corre- 
spond to the turns of the single and double spica-band- 
ages of the groin. 

I have described a few of the many ingenious bandages 



42 



BANDAGING. 



devised by Mayor to substitute the use of the roller- 
bandage, which will give the student some idea of their 



Fig. 37. 










Gluteo-femoral triangle. 
Fig. 38. 




Gluteo-inguinal cravat. 



design and application. It is well to bear in mind this 
system of dressing, for the occasion might occur in which 



BANDAGES OF THE HEAD. 43 

the ordinary means of bandaging could not be obtained, 
and the use of handkerchiefs might answer a useful pur- 
pose as temporary dressings. I think their principal use 
is for temporary dressings, and I do not believe they will 
ever take the place of the roller-bandage, which can be 
applied with greater nicety and exactness, and certainly 
presents a much neater appearance. 



BANDAGES OF THE HEAD. 

Barton's Bandage. Roller Two Inches in Width, Six 
Yards in Length. — The initial extremity of the roller 
should be placed on the head just behind the mastoid 
process, and the bandage should then be carried under the 
occipital protuberance obliquely upward under and in front 
of the parietal eminence across the vertex of the skull, 
then downward over the zygomatic arch, under the chin, 
thence upward over the opposite zygomatic arch and over 
the top of the head, crossing the first turn which was made, 
as nearly as possible in the median line of the skull, and 
carrying the turns of the roller under the parietal eminence 
to the point of commencement. The bandage is then 
passed obliquely around under the occipital protuberance 
and forward under the ear to the front of the chin, thence 
back to the point from which the roller started. These 
figure-of-eight turns over the head and the circular turns 
from the occiput to the chin should be repeated, each turn 
exactly overlapping the preceding one until the bandage 
is exhausted (Fig. 39). The extremity should then be 
secured by a pin ; and pins should be introduced at the 
points where the turns cross each other, to give additional 
fixation to the bandage. In applying the bandage, care 
should be taken to see that the turns overlap each other 
exactly, and that the turns passing over the vertex cross 
as nearly as possible in the median line of the skull 
(Fig. 40). 

Modified Barton's Bandage. — To obtain additional 
security in the application of the Barton's bandage, a turn 



44 



BANDAGING. 



of the bandage passing from the occiput to the forehead 
may be made, this turn being interposed between the turns 
of the bandage as ordinarily applied (Fig. 41). In ap- 
plying this bandage, after the first set of turns has been 
completed — that is, after the bandage has been brought 
back to the occiput — the bandage is carried forward upon 
the head just over the ear, around the forehead and back- 
ward above the ear on the opposite side to the occiput ; 
this being done, the ordinary figure-of-eight and circular 



Fig. 39. 



Fig. 40. 





Barton's bandage. 



Barton's bandage, showing crossing 
of turns at vertex. 



turns are made, and when these have been completed 
another occipito-frontal turn may be made as described 
above, and this may be repeated as often as is desired 
until the bandage is exhausted, when the extremity is fast- 
ened with a pin, and pins are introduced also at all points 
at which the turns cross. 

Use. — This bandage is one of the most useful of the 
bandages of the head, being employed to secure fixation 
of the jaw in cases of fracture or dislocation, and for the 
application of dressings to the chin. I have also employed 



BANDAGES OF THE HEAD. 45 

it in place of the head-gear in slinging patients for the 
application of the plaster-of-Paris jacket in cases of dis- 
ease of the spine, a stout cord or a piece of bandage about 
three inches wide and one yard long being passed under 
the turns crossing over the vertex ; this cord is then se- 
cured to the cross-bar of the extension apparatus (Fig. 42). 
This will be found quite as comfortable to the patient as 

Fig. 41, 




Modified Barton's bandage. 

the ordinary head-gear employed, and much less likely to 
slip out of place and interfere with the breathing of the 
patient. 

A firmly applied Barton's bandage holds the jaws so 
closely together that care should be taken in applying it 
to patients who are under the influence of an anaesthetic, 
for if vomiting occurs the material may not escape from 
the mouth, and suffocation might occur unless the bandage 



46 



BANDAGING. 



were promptly removed. This accident I once saw occur, 
and the patient's condition was alarming until the bandage 
was cut, allowing the jaw to be opened and the contents 
of the mouth to escape. 

Gibson's Bandage. Roller Two Inches in Width, Six 
Yards in Length. — The initial extremity of the roller 

should be placed upon the 
vertex of the skull in a line 
with the anterior portion of 
the ear ; the bandage is then 
carried downward in front of 
the ear to the chin, and passed 
under the chin, and is carried 
upward on the same line until 
it reaches the point of starting. 
The turns are repeated until 
three complete turns have been 
made ; the bandage is then con- 
tinued until it reaches a point 
just above the ear, when it is 
reversed and is carried back- 
ward around the occiput, and 
is continued around the head 
and forehead until it reaches 
its point of origin ; these cir- 
cular turns are applied until 
three have been made. When 
the bandage reaches the occi- 
put, having completed the third 
turn, it is allowed to drop down 
to the base of the skull, and it is then carried forward 
below the ear and around the chin, being brought back 
upon the opposite side of the head and neck to the point 
of origin ; these turns are repeated until three complete 
turns have been made, and upon the completion of the 
third turn the bandage is reversed and carried forward 
over the occiput and vertex to the forehead, and its 
extremity is here secured with a pin. Pins should also 




Barton's he ad -band age, employed 
for suspension. 



BANDAGES OF THE HEAD. 



47 



be applied at the points where the turns of the bandage 
cross each other (Fig. 43). 

Use. — This bandage may be used to fix the lower jaw in 
cases of fracture or dislocation of the jaw, but is very apt 
to change its position, and is, therefore, not so satisfactory 
as the Barton's bandage for this purpose. 

Fig. 43. 




Gibson's bandage. 

Oblique Bandage of the Angle of the Jaw. Boiler 
Two Inches in Width, Six Yards in Length. — The initial 
extremity of the roller is placed just in front of and above 
the left ear, and if the left angle of the lower jaw is to be 
covered in, the bandage is then carried from left to right, 
making two complete turns around the cranium from the 
occiput to the forehead ; if, however, the right angle of 
the lower jaw is to be covered in, the turns should be made 
in the opposite direction. Having made two turns from 
the occiput to the forehead, the bandage is allowed to drop 
down upon the neck, and is carried forward under the ear 
and under the chin to the angle of the jaw ; it is next 
carried upward close to the edge of the orbit, and obliquely 
over the vertex of the skull, then down behind the right 
ear, continuing this oblique turn under the chin to the left 



48 



BANDAGING. 



Fig. 44. 



angle of the jaw, where it ascends in the same direction as 
the previous turn. Three or four of these oblique turns 
are made, each turn overlapping the preceding one and 
passing from the edge of the orbit toward the ear until 
the space is covered in ; the bandage is then carried to a 
point just above the ear on the opposite side, is reversed, 
and finished with one or two circular turns from the occi- 
put to the forehead, the extrem- 
ity being secured by a pin (Fig. 
44). 

Use. — This will be found one 
of the most useful of the head- 
bandages ; it may be used with 
a compress in treating fractures 
of the angle of the lower jaw, 
for holding dressings to the 
lower part of the chin and to 
the vault of the cranium, and 
is especially useful in retaining 
dressings to the sides of the 
face and the parotid region. As 
before stated, it may be applied 
to cover either the right or left 
side of the face, and, by reason 
of the oblique turns, holds its 
position most securely, having little tendency to become 
displaced. 

Recurrent Bandage of the Head. Roller Two Inches 
in Width, Six Yards in Length. — The initial extremity of 
the roller is placed upon the lower part of the forehead 
and the bandage is carried twice around the head from the 
forehead to the occiput to secure it. When the bandage 
is brought back to the median line of the forehead it is 
reversed, and the reversed turn is held by the finger of the 
left hand while the roller is carried over the top of the 
head along the sagittal suture to a point just below the 
occipital protuberance ; here it is reversed again, and the 
reverse is held by an assistant while the roller is carried 
back to the forehead in an elliptical course, each turn cov- 




Oblique bandage of the angle of 

the jaw.. 



BANDAGES OF THE HEAD. 49 

ering in two-thirds of the preceding turn. These turns 
are repeated with successive reverses at the forehead and 
occiput until one side of the head is completely covered in, 
and when this is accomplished a circular turn is made from 
the forehead to the occiput to hold the reverses in place. 

The opposite side of the head is next covered in by ellip- 
tical reversed turns made in the same manner, and when 
this has been accomplished two or three circular turns are 
carried around the head from the forehead to the occiput, 
to fix the preceding turns. Pins should be applied at the 

Fig. 45. 




Recurrent bandage of the head. 

forehead and occiput at the points where the reversed turns 
concentrate (Fig. 45). 

Use. — This bandage when well applied is one of the 
neatest of the head-bandages, and it will be found useful 
to retain dressings to the vault of the cranium in the treat- 
ment of wounds of the scalp in this region. It will also 
be found of service in holding dressings to fractures of the 
cranium and to wounds after the operation of trephining. 
In restless patients it will sometimes become displaced, and 
it may be rendered more secure by pinning a strip of band- 
age to the circular turn in front of the ear and carrying 
4? 



50 



BANDAGING. 



Fig. 46. 



it down under the chin and up to a corresponding point 
on the opposite side, where it is pinned to the circular 
turn ; or one or two oblique turns passing from the circu- 
lar turn over the vertex of the skull downward behind 
the ear, under the chin and up to the circular turn in front 
of the ear, may be applied. The course of these turns is 
the same as those employed in the oblique bandage of the 
angle of the jaw, the extremity being secured by a pin. 

Transverse Recurrent Bandage of the Head. Roller 
Two Inches in Width, Six Yards in Length. — The initial 
extremity of the roller is placed upon the lower part of the 

forehead and the bandage is 
carried twice around the head 
from the forehead to the occi- 
put to secure it. The head is 
then covered in by transverse 
turns of the bandage ; the first 
turn, starting from a point be- 
hind the ear on one side, is 
carried below the occiput to a 
corresponding point behind the 
opposite ear, and ascending 
transverse turns are then made 
and carried over the head, each 
turn covering in about two- 
thirds of the preceding turn, 
until the forehead is reached, 
and when this has been reached 
two or three circular turns are 
carried around the head from the forehead to the occiput 
to fix the recurrent turns. Pins should be applied at the 
points of starting and finishing of the reversed turns be- 
hind the ears, and at the occiput and forehead (Fig. 46). 
Use. — This bandage may be employed to secure dress- 
ings to the scalp in cases of wounds or in injuries to the 
skull, and is used for the same purposes as the recurrent 
bandage of the head. 

V-bandage of the Head. Roller Two Inches in Width, 
Four Yards in Length. — The initial extremity of the roller 




Transverse recurrent bandage of 
the head. 



BANDAGES OF THE HEAD. 



51 



is secured by two turns of the bandage around the cra- 
nium from the forehead to the occiput, and when the 
roller reaches the occipital protuberance it is allowed to 
drop a little below this, and is carried forward below 
the ear around the front of the chin and lower lip, then 
backward to the point of starting. These turns passing 
from the occiput to the forehead and from the occiput to 
the chin are alternately made until a sufficient number 
have been applied, and the extremity is secured by a pin 
over the occiput (Fig. 47). 



Fig. 47. 



Fig. 48. 




V-bandage of the head. 



Head-and-neck bandage. 



This bandage may be modified by carrying the turns from 
the occiput forward under the ear and around the upper lip 
and back to the occiput, and alternating these turns with 
the occipitofrontal turns ; if employed in this way, a band- 
age of one and one-half inches in width should be used. 

Use. — This bandage may be employed to hold dressings 
to the front of the chin, to the upper and lower lips in 
cases of wounds, or to give support to these parts after 
plastic operations. 

Head-and-neck Bandage. Roller Two Inches in Width, 
Four Yards in Length. — The initial extremity of the roller 
is placed upon the forehead and carried backward just 



52 



BANDAGING. 



above the ear to the occiput, arid is then brought forward 
around the opposite side of the head to the point of start- 
ing. Two of these circular turns are made to fix the 
bandage, and when it is carried back to the occiput it is 
allowed to drop down slightly upon the neck, and is then 
carried around the neck, the turns around the head alter- 
nating with the neck-turns until a sufficient number of 
these have been applied, when the extremity of the bandage 
is secured by a pin at the point of crossing of the turns 
at the back of the head (Fig. 48). 

Use. — This bandage may be found useful in securing 
dressings to the anterior or posterior portion of the neck 
or to the region of the occiput. Care should bo taken to 
apply it in such a manner that too much pressure is not 
made by the turns around the neck, which would be un- 
comfortable to the patient, and might seriously interfere 
with respiration. 

Crossed Bandage of One Eye. Roller Two Inches in 
Width, Four Yards in Length. — The initial extremity of 
the bandage is placed upon the forehead and fixed by two 

circular turns passing around the 

head from the occiput to the fore- 

, ^ head; the roller is then carried 

^^r back to the occiput and passed 

fff around this and brought forward 

below the ear, and passing over 
the outer portion of the cheek is 
carried upward to the junction of 
the nose with the forehead, and is 
then conducted over the parietal 
eminence downward to the occi- 
put ; a circular fronto-occipital 
turn is next made, and when the 
bandage is brought back to the oc- 
ciput it is brought forward again 
to the cheek. It should then ascend to the forehead, 
covering in two-thirds of the preceding turn, and again be 
conducted back to the occiput ; these turns are repeated, 
the oblique turns covering the eye alternating with circu- 



Fig. 49. 




Crossed bandage of one eye. 



BANDAGES OF THE HEAD. 



53 



lar turns around the head until the eye is completely en- 
closed (Fig. 49), and the bandage is finished by making 
a circular turn about the head and introducing a pin to 
secure its extremity. It will be found more comfortable 
to the patient to include in the turns of the bandage the 
ear on the same side on which the eye is covered. 

Use. — This bandage will be found useful in retaining 
dressings to one eye. It will be more comfortable to the 
patient if a flannel roller be used to apply this bandage, as 
well as the bandage which includes both eyes. 

Crossed Bandage of Both Eyes. Roller Two Inches 
in Width, Six Yards in Length. — The initial extremity of 
the roller is placed upon the forehead and secured by two 
circular turns of the bandage passing around the head 
from the forehead to the occiput; the roller is then carried 
downward behind the occiput and brought forward below 
the ear to the upper portion of the cheek; it is then car- 
ried upward to the junction of the nose with the forehead 
and conducted over the parietal eminence to the occiput; 
a circular turn is now made around 
the head from the occiput to the 
forehead, and the roller is carried 
from the occiput over the parietal 
eminence of the opposite side for- 
ward to the junction of the nose 
with the forehead, then downward 
over the eye and outer portion of 
the cheek below the ear and back to 
the occiput; a circular turn around 
the head is next made, and this is 
followed by a repetition of the pre- 
vious turns, ascending over one eye, 
descending over the other eye, each 

turn alternating with a circular Crossed bandage of both eyes. 

turn around the head. These turns 

are repeated until both eyes are covered in, and the band- 
age is finished by making a circular turn around the head, 
the extremity being secured by a pin (Fig. 50). In this 
bandage both ears may be covered in or left uncovered. 




54 



BANDAGING. 



Use. — This bandage may be used to apply dressings to 
botli eyes, and both of these bandages covering the eyes 
are used where it is desired to make pressure ; but for the 
simple application of a light dressing or of a bandage for 
the exclusion of light, the Liebreich's bandage (Fig. 101) 
will be found more comfortable to the patient. 

OccipitO-facial Bandage. Roller Tivo Inches in Width, 
Four Yards in Length. — The initial extremity of the roller 
is placed upon the vertex „f the head and the bandage is 
carried downward in front )f the ear, under the jaw, and 
upward upon the opposite side in the same line to the ver- 
tex ; two or three of these turns are made, »ne turn accu- 
rately covering in the other. A reverse should be made 
just above and in front of the ear, and two or three turns 
are then made around the head from the occiput to the 
forehead, which completes the bandage (Fig. 51). Pins 
should be inserted at the points where the turns of the 
bandage cross each other. 

Use. — This bandage is employed to secure dressings to 
the vertex, temporal, occipital, or frontal region. 



Fig. 51. 



Fig. 52. 





Occipito-facial bandage. 



Oblique bandage of the head. 



Oblique Bandage of the Head. Boiler Two Inches in 
Width, Six Yards in Length, — The initial extremity of the 
bandage is placed upon the forehead, and is secured by 



BANDAGES OF THE HEAD. 



55 



Fig. 53. 



two circular turns passing around the head from the fore- 
head to the occiput. From the occiput the bandage is 
carried obliquely over the highest part of the lateral aspect 
of the head, which is to be covered in, and is passed over 
the forehead and back to the occiput. It is then carried 
to the forehead by a circular turn, which is conducted 
obliquely over the other side of the head and back to the 
occiput. A circular turn from the occiput to the forehead 
should be made between the oblique turns. These turns 
are repeated, so that each succeeding turn covers in three- 
fourths of the preceding turn until the sides of the head 
are covered in by descending turns, and the bandage is 
completed by a circular turn passing around the head from 
the forehead to the occiput 
(Fig. 52). This bandage may 
be applied with descending or 
ascending turns. 

Use. — This bandage is em- 
ployed to make pressure upon 
or to hold a dressing to the 
lateral aspects of the head. 

Occipito-frontal Bandage. 
Roller Two Inches in Width, 
Four Yards in Length. — The 
initial extremity of the roller 
is placed upon the forehead, 
and a circular turn is made 
around the forehead and occi- 
put to fix it. A circular turn 
is then made, passing around occipitofrontal bandage. 

the head from a point below the occiput to a point just 
above the forehead ; the next circular turn is made around 
the head ascending posteriorly and descending anteriorly, 
and after a sufficient number of these turns have been 
made to cover in the front and back of the head the end 
of the bandage is secured with a pin (Fig. 53). 

Use. — This bandage will be found useful in securing 
dressings to the forehead and anterior and posterior por- 
tions of the scalp. 




56 



BANDAGING. 



BANDAGES OF THE UPPER EXTREMITY. 

Spiral Bandage of the Finger. Roller One Inch in 
Width, One and a Half Yards in Length — The initial ex- 



Fig. 54. 



Fig. 55. 




Spiral bandage of the finger. 



Spiral reversed bandage of fingers. 



tremity of the roller is secured by two or three turns 
around the wrist ; the bandage is then carried obliquely 
across the back of the hand to the base of the finger to 
be covered in, then to its tip by oblique turns ; a circular 
turn is next made, and the finger is covered by ascending 
spiral or spiral reversed turns until its base is reached ; 
the bandage is then carried obliquely across the back of 
the hand and finished by one or two circular turns around 
the wrist ; the extremity may be pinned or may be split 
into two tails which are tied around the wrist (Fig. 54). 
Use. — This bandage is employed to retain dressings to 
injuries or wounds upon the finger, and to secure splints in 
the treatment of fractures or dislocations of the phalanges. 



BANDAGES OF THE UPPER EXTREMITY. 57 

Spiral Reversed Bandage of Fingers. Roller One 
and a Half Inches in Width, One and a Half Yards in 
Length. — The initial extremity of the roller may be 
secured by two or three turns around the wrist ; the 
bandage is then carried obliquely across the back of the 
hand to the base of the fingers to be covered in, then to 
their tips by oblique turns ; a circular turn is next made 
and the fingers are covered in spiral reversed turns until 
their bases are reached ; the bandage is then carried 
obliquely across the back of the hand and finished by 
one or two circular turns around the wrist ; the end of the 
bandage may be secured by a pin or split into two tails 
which are tied around the wrist (Fig. 55). 

This bandage may also be applied so as to cover the 
fingers alone by making one or two circular turns around 
the base of the fingers and then carrying the bandage 
obliquely down to the tips of the fingers, there making a cir- 
cular turn and then conducting it back to the base of the 
fingers by spiral reversed turns, and at this point it is 
secured by a pin or by tying. This bandage does not hold 
its position as securely as the one first described. 

Use. — This bandage is employed to secure dressings to 
two or more fingers or to retain a splint in contact with 
them. 

Gauntlet Bandage. Roller One Inch in Width, Three 
Yards in Length. — The initial extremity of the roller is 
fixed at the wrist by one or two circular turns of the 
bandage ; it is then carried down to the tip of the thumb 
by an oblique turn of the roller, and this is covered in by 
spiral or spiral reversed turns to the metacarpophalangeal 
articulations ; the roller is then carried back to the wrist 
and a circular turn is made around it. The bandage is 
tnen carried down to the tip of the index finger by an 
oblique turn, which is covered in the same manner. When 
all the fingers have been covered in, the bandage is finished 
by circular turns around the hand and wrist. (Fig. 56). 

Use. — This bandage may be employed to apply dressings 
to the fingers and hand in cases of wounds or fractures. 
It was formerly much employed in the treatment of burns 
of the fingers to prevent the opposed ulcerated surfaces 



58 



BANDAGING. 



from adhering, but its use for thio purpose has been sup- 
planted by wrapping each finger in a separate dressing and 
applying a bandage over all the fingers and the hand with a 
few recurrent and spiral turns of a wide roller, the applica- 
tion of this dressing being much less painful to the patient, 



Fig. 56 




Gauntlet bandage. 



Demi-gauntlet bandage. 



and being at the same time equally satisfactory in its 
results. 

Demi-gauntlet Bandage. Roller One Inch in Width, 
Four Yards in Length. — The initial extremity of the 
bandage should be placed upon the wrist and fixed by two 
circular turns passing from the radial to the ulnar side; 
then carry the roller obliquely across the back of the hand 
to the base of the little finger, pass the bandage around this 
and carry the roller back to the wrist, making a circular 
turn ; it should then be carried obliquely across the hand to 
the base of the ring finger, and so successively until the base 
of each of the fingers and of the thumb has been included; 
the bandage is then completed by an oblique turn across the 
back of the hand, passing between the index finger and the 
thumb, and a circular turn around the wrist (Fig. 57). 



BANDAGES OF THE UPPER EXTREMITY. 



59 



The demi-gauntlet bandage may also be applied in such 
a manner as to cover over the palm and leave the dorsum 
of the hand uncovered. 

Use. — This bandage may be employed to retain light 
Iressings to the dorsal or palmar surface of the hand. 

Fig. 58. 



Fig. 59. 





Complete bandage of hand. 



Spica-bandage of the thumb. 



Complete Bandage of Hand. Roller Two Inches 
in Width, Two Yards in Length. — The initial extremity 
of the bandag3 is placed upon the wrist and the hand is 
covered in by three or four recurrent turns, and these are 
secured by a circular turn around the wrist. The bandage 
is then carried obliquely across the back of the hand to 
the tip of the index finger, when a circular turn is made 
around the tip of the fingers ; the bandage is then carried 
upward by spiral or spiral reversed turns covering in all 
of the fingers and the thumb as well as the body of the 
hand, and is completed by one or two circular turns 
around the wrist. This bandage may also be applied so 
as to leave the thumb uncovered (Fig. 58). 

Use. — This bandage may be employed to secure dress- 
ings to the hand. 



60 BANDAGING. 

Spica-bandage of the Thumb. Roller One Inch in 
Width, Three Yards in Length. — The initial extremity of 
the roller is placed upon the wrist and fixed by two circu- 
lar turns ; then carry the roller obliquely over the dorsal 
surface of the thumb to its distal extremity ; next make a 
circular or spiral turn around the thumb, and carry the 
bandage upward over the back of the thumb to the wrist, 
around which a circular turn should be made. The roller 
is then carried around the thumb and wrist, making figure- 
of-eight turns, each turn overlapping the previous one 
two-thirds as it ascends the thumb, and each figure-of- 
eight turn alternating with a circular turn around the 
wrist. These turns are repeated until the thumb is com- 
pletely covered in with spica-turns ; a circular turn around 
the wrist finishing the bandage (Fig. 59). 

Fig. 60. 




Spiral reversed bandage of arm. 

Use. — This bandage is employed to apply dressings to 
the dorsal surface of the thumb and for the retention of 
splints in the dressing of fractures or dislocations of the 
bones of the thumb. 

Spiral Reversed Bandage of Arm. Boiler Two and 
a Half Inches in Width, Five Yards in Length. — The 
initial extremity of the bandage is secured by one or two 
circular turns around the arm just above the elbow and is 
then carried up the arm by spiral reversed turns until the 
axilla is reached where the extremity is secured. Care 



BANDAGES OF THE UPPER EXTREMITY. 



61 



should be used in applying this bandage that it is not 
applied so firmly that it causes venous obstruction and 
swelling of the forearm (Fig. 60). 

Use. — This bandage is employed to secure dressings or 
splints to the arm. 

Spiral Reversed Bandage of the Upper Extremity. 
Boiler Two and a Half Inches in Width, Seven Yards in 
Length. — The initial extremity of the roller is placed upon 
the wrist, and secured by two turns around the wrist ; the 
bandage is then carried obliquely across the back of the 
hand to the second joint of the fingers, where a circular 
turn should be made ; the hand is covered in by two or 

Fig. 61. 









!!lli^Muairt 


ggfff 


^ 





Spiral reversed bandage of the uppe? extremity. 

three ascending spiral or spiral reversed turns. When the 
thumb has been reached, its base and the wrist are covered 
in by two figure-of-eight turns ; the bandage is then carried 
up the forearm by spiral and spiral reversed turns until the 
elbow is reached ; this may be covered in with spiral re- 
versed turns, and the bandage is next carried up the arm 
with spiral reversed turns to the axilla (Fig. 61). If, on 
reaching the elbow, the arm is bent, or is to be flexed in 
the subsequent dressing, the elbow should be covered in 
with figure-of-eight turns, and when this has been done 
the arm may be covered in with spiral reversed turns. 
When properly applied, the reverses should be in line, 
and should not be made over the prominent ridge of the 
ulna, 



62 



BAND A GING. 



Use. — This is one of the most generally employed of all 
the roller-bandages ; it constitutes the primary roller which 
is applied in the dressing of fractures of the humerus, and 
it is also the bandage employed in holding dressings to the 
arm and forearm and in securing splints to these parts in 
the treatment of fractures and dislocations. 

Figure-of-eight Bandage of the Elbow. Boiler Two 
Inches in Width, Four Yards in Length. — The initial ex- 
tremity of the bandage is placed upon the forearm a short 
distance below the elbow-joint, and fixed by one or two 



Fig. 62. 




Figure-of-eight bandage of the elbow. 

circular turns, the arm being flexed. The bandage is then 
carried by an oblique turn across the flexure of the elbow- 
joint, and passed around the arm a few inches above the 
elbow ; a circular turn is then made, and the roller is next 
carried across the flexure of the elbow and passed around 
the forearm. These turns are repeated, the turns from the 



BANDAGES OF THE UPPER EXTREMITY. 



63 



forearm ascending and those from the arm descending, 
each set of turns crossing in the flexure of the elbow until 
it is covered in, and a final turn is passed circularly around 
the elbow joint (Fig. 62). This bandage is sometimes 
applied by first making one or two circular turns around 
the elbow and then applying the figure-of-eight turns as 
previously described (Fig. 63). 

Use. — This bandage is often employed as a part of the 
spiral reversed bandage of the upper extremity when the 
arm is to be flexed, and is also used to hold dressings to 
the region of the elbow-joint. It was formerly much used 

Fig. 63. 




Figure-of eight bandage with primary turns around the elbow. 

to hold the compress upon the wound resulting from vene- 
section at the elbow. 

Spica-bandage of the Shoulder (Ascending). Roller 
Two and a Half Inches in Width, Seven Yards in Length. 
— The initial extremity of the roller is placed obliquely 
upon the outer surface of the arm opposite the axillary 
fold, and fixed by one or two circular turns. If the right 
shoulder is to be covered, the bandage is next carried across 
the front of the chest to the axilla of the opposite side, 



64 BANDAGING. 

then around the back of the chest to the point of starting 
upon the arm ; then the roller should be conducted around 
the arm of this side up over the shoulder, across the front 
of the chest, through the opposite axilla, and back over the 
posterior surface of the chest to the point of starting ; con- 
tinue to make these ascending turns, each turn overlapping 
the preceding one about two-thirds until the shoulder is 
covered in (Fig. 64). when the extremity of the bandage 
may be secured by a pin at the point of ending, or the last 
turn may be carried from the shoulder around the back of 
the neck and brought forward over the opposite shoulder 

Fig. 64. 




Spica-bandage of the shoulder (ascending). 

and pinned to the turns which pass around the axilla. It 
should be remembered that the turns of the roller overlap 
each other exactly in the opposite axilla, and it will be 
found more comfortable to the patient to place a little 
cotton-wadding in the axilla to prevent the bandage from 
excoriating the skin of this part. Care should be taken 
to see that the turns are made in such a manner that the 
spica-turns occupy as nearly as possible the median line 
of the shoulder. When this bandage is applied to the 
left shoulder, after fixing the initial extremity by circular 
turns around the arm, the roller should be carried over 



BANDAGES OF THE UPPER EXTREMITY. 65 

the back of the chest to the axilla of the opposite side and 
then brought back to the point of starting ; the succeed- 
ing turns are then applied in the same manner. 

Spica-bandage of the Shoulder (Descending). Roller 
Two and a Half Inches in Width, Seven Yards in Length. — 
The initial extremity of the roller should be fixed upon 
the arm as near as possible to the axillary fold by one or 
two circular turns ; and if it is applied to the right shoul- 
der, the bandage should be passed under the axilla and 
carried obliquely over the shoulder to the base of the neck, 

Fig. 65. 




Spica-bandage of the shoulder (descending). 

then downward across the front of the chest to the axilla 
of the opposite side ; from the axilla the roller is carried 
over the back of the chest to the base of the neck, so as to 
cross the first turn at this point ; it is then carried through 
the axillary space, then back to the neck, the turns de- 
scending toward the shoulder. These turns, taking the 
same course, are repeated, each turn overlapping two- 
thirds of the previous one until the shoulder is covered in 
and the circular turn around the arm is reached, at which 
point the extremity is secured by a pin (Fig. 65). 

Use. — The spica-bandages of the shoulder are employed 

5 



66 



BANDAGING. 



Fig. 66. 




Figure-of-eight bandage of the 
neck and axilla. 



to hold dressings to the shoulder, to hold compresses over 
the acromial end of the clavicle in dislocation of that 
portion of the bone, to retain the shoulder-cap used in 
the treatment of fractures of the upper portion of the 

humerus, and to retain dress- 
ings to the axilla. 

Figure-of-eight Bandage 
of the Neck and Axilla. 
Roller Two Inches in Width, 
Five Yards in Length. — The 
initial extremity of the roller 
is fixed upon the side of the 
neck and secured by one or 
two loosely applied circular 
turns ; if applied to the right 
axilla, carry the bandage from 
left to right over the right 
shoulder to the posterior part 
of the axilla under which it passes, to ascend in front over 
the same shoulder to the back of the neck ; these figure- 
of-eight turns around the neck and axilla, each turn over- 
lapping two-thirds of the preceding turn, are repeated 
until the desired space is covered and the bandage is 
completed by a circular turn around the neck (Fig. 66). 

Use. — This will be found a useful bandage to secure 
dressings to the base of the neck, the upper part of the 
shoulder, and to the axilla, as it does not restrict the 
motions of the arm unless drawn too tight. 

Velpeau's Bandage. Two Boilers Two and a Half 
Inches in Width, Seven Yards in Length. — The patient 
should place the fingers of the hand of the affected side on 
the opposite shoulder ; the initial end of the roller should 
be placed on the body of the scapula of the sound side 
and secured by a turn made by carrying the bandage over 
the shoulder of the affected side, near its outer portion, 
then conducting it downward over the outer and posterior 
surface of the arm of the same side, behind the point of 
the elbow, and obliquely across the front of the chest to 
the axilla of the opposite side, thence to the point of start- 



BANDAGES OF THE UPPER EXTREMITY. 



67 



ing. This turn should be repeated, to fix the initial ex- 
tremity of the bandage. Having completed the second 
turn, carry the roller transversely around the thorax, pass- 
ing over the flexed elbow of the aifected side, from this 
x>int to the axilla, and through this to the back. From 
this point the roller is carried over the shoulder and 
down the outer and posterior surface of the arm behind the 
elbow, and obliquely across the front of the chest through 
the axilla to the back, and, continuing, passes transversely 

Fig. 67. 




Velpeau's bandage. 



across the back of the chest to the elbow, which it en- 
circles, and then passes to the axilla. These alternating 
turns are repeated until the arm and forearm are bound 
firmly to the side and chest. The vertical turns over the 
shoulder, each turn covering in two-thirds of the previous 
turn and ascending from the point of the shoulder toward 
the neck and from the posterior surface of the arm toward 
the elbow, are applied until the point of the elbow is 
reached. The transverse turns passing around the chest 
and arm are so applied that they ascend from the point 
of the elbow toward the shoulder, each turn covering in 



68 BANDAGING. 

one-third of the previous one, and the last turn should 
pass transversely around the shoulder and chest, covering 
the wrist (Fig. 67). 

The extremity of the bandage should be secured by a 
pin where it ends, and additional fixation will be secured 
by introducing a number of pins at the points where the 
turns of the bandage cross each other. 

Use. — This bandage is employed to fix the arm in the 
treatment of certain fractures of the clavicle and scapula ; 
also to secure fixation of the humerus after the reduction 
of dislocations of the shoulder-joint. 

Desault's Bandage. Three Rollers Ttvo and a Half 
Inches in Width, Seven Yards in Length.- — A wedge-shaped 
pad to fit in the axilla is also required. These rollers are 
known as the first, second, and third rollers. 

First Roller of Desault's Bandage. — Before applying the 
first roller the arm of the patient on the injured side should 

Fig. 68. 




First roller of Desault's bandage. 

be elevated and carried off at right angles to the body ; the 
wedge-shaped pad with its base in the axilla should next 
be applied to the side of the chest, and the initial extrem- 
ity of the roller should be placed upon the middle of the 
pad, which may be fixed by two or three circular turns 
around the chest ; the bandage is then carried down the 



BANDAGES OF THE UPPER EXTREMITY. 



69 



chest by oblique circular turns until the lower extremity 
of the pad is reached, and it is then carried up the chest 
by spiral turns until the upper extremity of the pad is 
reached, when it is conducted obliquely across the front 
of the chest to the sound shoulder and passed under the 
axilla, brought over the shoulder and conducted around 
the chest, where it is secured (Fig. 68). 

Second Roller of Desault's Bandage. — The arm should be 
brought down against the side so as to press upon the pad 
previously applied, and the forearm should be flexed upon 
the arm and brought across the lower portion of the chest. 

Fig. 69 




Second roller of Desault's bandage. 



The initial extremity of the roller is placed in the axilla 
of the sound side, and the bandage is carried around the 
chest and over the arm of the injured side, making a cir- 
cular turn around the chest to fix it ; then spiral turns are 
made around the chest from above downward until the 
elbow is reached, the turns being more firmly applied as 
they descend, and when this point is reached the end of 
the bandage is secured. Or the initial extremity of the 
bandage may be placed upon the chest of the sound side 
and a circular turn may be made to fix it, and then spiral 
turns, including the chest and arm, may be made from 
below upward until the axilla is reached (Fig, 69). 



70 



BANDAGING. 



Third Roller of Desault's Bandage. — The initial extremity 
of the roller is placed in the axilla of the sound side, and 
the bandage is carried obliquely over the front of the chest 
to the shoulder of the injured side, passed over this, and 
conducted down the back of the arm to the elbow, thence 
obliquely upward over the upper fifth of the forearm to 
the axilla of the sound side. From this point it is carried 
backward obliquely over the back of the chest to the shoul- 
der ; crossing the previous shoulder-turn, it is conducted 
down the front of the arm to the elbow T , then around this 
and backward obliquely over the back of the chest to the 

Fig. 70. 




Third roller of Desault's bandage. 

axilla of the sound side. These turns are repeated until 
three sets of turns have been applied, which should overlie 
each other exactly (Fig. 70). The course of the turns of 
the third roller is considered the most difficult to remem- 
ber, and the student may be assisted in its correct applica- 
tion by remembering that all the turns start at the axilla, 
pass to the shoulder, and then to the elbow, and from the 
elbow always return to the starting-point — the axilla. 
The turns of the third roller make two triangles, one on 
the anterior surface of the chest (Fig. 71), the other upon 
the back (Fig. 72). 

After the application of the three rollers the hand and 



BANDAGES OF THE UPPER EXTREMITY. 



71 



uncovered portion of the forearm should be supported in 
a sling suspended from the neck. 

Use. — This bandage, applied completely, or some one of 
its various rollers, is employed in the treatment of fractures 
of the clavicle. 



Fig. 71. 




Fig. 72. 




Anterior view of the turns of third 
roller of Desault's bandage. 



Posterior view of the turns of third 
roller of Desault's bandage. 



Arm-and- chest Bandage. Roller Two and a Half 
Inches in Width, Seven Yards in Length. — Before applying 
this bandage, the arm should be placed against the side of 
the chest and a folded towel or a pad of cotton should be 
placed in the axilla and allowed to extend from the axilla 
to the elbow ; the latter is used to prevent the opposing 
surfaces of skin from becoming excoriated by contact. 



72 



BANDAGING. 



The initial extremity of the bandage is placed upon the 
spine at a point opposite the elbow-joint, and it is fixed by 
a turn or two passing around the arm and chest ; the band- 
age is then continued by making ascending, spiral turns, 
covering in the arm and chest until the axilla is reached ; 
at this point the bandage is carried through the axilla of 
the sound side and over the back of the chest to the top of 

Fig. 73. 




Arm-and-chest bandage. 

the opposite shoulder, and it is then conducted down the 
front of the arm to the elbow, is passed between the arm 
and chest, and carried up the back of the arm to the 
shoulder. It is then passed obliquely across the front of 
the chest, and is secured upon the back of the chest. Pins 
should be introduced at the points of crossing of the 
bandage (Fig. 73). 



BANDAGES OF THE TRUNK. 



73 



Use. — This bandage will be found useful in fixing the 
arm to the body and in fixing the shoulder-joint where it 
is desirable to allow the forearm to be free. It is em- 
ployed in the treatment of fractures of the shaft and neck 
of the humerus to fix the arm and hold splints in position. 



Fig. 74. 



BANDAGES OF THE TRUNK. 

Spiral Bandage of the Chest. Roller Three Inches in 
Width, Nine Yards in Length. — The initial extremity of 
the roller is applied to the anterior portion of the waist, 
and fixed by one or two circular turns ; the bandage is 
then carried upward, encircling the chest by ascending 
spiral turns, each turn covering in one-half of the previous 
turn until the axillary fold is reached ; the roller is next 
carried around the axilla to the back, and obliquely over 
this to the base of the neck of the opposite side, and 
then it may be passed down over the chest and pinned 
to the spiral turns at several points ; a pin should also be 
inserted at the point where the last turn of the roller 
leaves the spiral turn upon the back of the chest (Fig. 74). 

Use. — This bandage is em- 
ployed to hold dressings to 
the chest, and may be used 
as a temporary dressing in 
fractures of the ribs or ster- 
num. Care should be taken 
that the bandage be not so 
tightly applied as to interfere 
with respiration. 

Anterior Figure-of-eight 
Bandage of the Chest. 
Roller Two and a Half Inches 
in Width, Seven Yards in 
Length. — The initial extrem- 
ity of the roller should be 

placed in the axilla of One Spiral bandage of the chest. 

side, and the bandage is then 

carried obliquely across the anterior portion of the chest 




74 



BANDAGING. 



to the shoulder of the opposite side ; it is then carried 
backward around the shoulder and through the axilla, and 
is next conducted obliquely over the anterior portion of 
the chest to the opposite shoulder, through the axilla, and 
again back to the anterior portion of the chest, the turns 
crossing in the median line over the sternum. These 
turns should be repeated, ascending from the shoulder 
toward the neck, each turn overlapping three-fourths of 
the preceding one, until five or six turns have been ap- 
plied, the end of the bandage being secured by a pin 

Fig. 75. 




Anterior figure-of-eight bandage of the chest. 



(Fig. 75), or it may be completed by a circular turn 
around the chest. 

Use. — This bandage may be employed to bring the 
shoulders forward, and to hold dressings to the anterior 
portion of the chest. 

Posterior Figure-of-eight Bandage of the Chest. 
Roller Two and a Half Inches in Width, Seven Yards in 
Length. — The initial extremity of the roller should be 
placed in the axilla of the left side, and the bandage should 
then be carried obliquely across the back of the chest to 
the top of the opposite shoulder ; it is next carried through 
the axilla and conducted across the posterior portion of the 
chest to the top of the opposite shoulder, and passed through 



BANDAGES OF THE TRUNK 



75 



the axilla to the point of starting. These turns are re- 
peated, descending from the neck toward the shoulder, until 
five or six have been applied, the end of the bandage be- 
ing secured by a pin (Fig. 76). In applying both of these 
bandages the crosses of the bandage, either anterior or 
posterior, should be made in the median line of the 
chest. 

Use. — This bandage may be employed to hold dress- 
ings to the posterior portion of the chest and to draw the 
shoulders backward. 

Fig. 76. 




Posterior figure-of-eight bandage of the chest. 



Suspensory and Compressor Bandage of the Breast. 

Roller Two and a Half Inches in Width, Seven Yards in 
Length. — The initial extremity of the roller should be 
placed upon the scapula of the affected side, and secured 
by two oblique turns carried over the opposite shoulder 
and conducted downward under the breast to be covered 
in, and then carried to the axilla of the same side. Next 
carry the roller transversely around the chest, covering in 
the lowest portion of the affected breast. These turns 
should be repeated, the oblique turns from the axilla over 
the shoulder alternating with the transverse turns around 
the chest, until the breast is covered in, each series of turns 



76 



BANDAGING. 



ascending and covering two-thirds of the preceding turns 
(Fig. 77). 

Use. — This bandage is employed to support the breast 
and to make compression at the same time ; it may also 
be employed to hold dressings to the breast. 



Fig. 77. 




Suspensory and compressor bandage of the breast. 



Suspensory and Compressor Bandage of Both 

Breasts. Two Rollers Two and a Half Inches in Width, 
Seven Yards in Length. — The initial extremity of the 
bandage should be secured by oblique turns of the axilla 
and shoulder, passing under one breast, as in the preceding 
bandage ; the roller should next be carried transversely 
around the back to the other breast, then under the breast 
and upward over the opposite shoulder, then obliquely 
downward around the chest to the other side, being carried 
transversely over the lower portion of both breasts to the 
point of starting upon the back. Repeat these oblique 
turns from the shoulder to the breast and from the breast 
to the shoulder, and alternate them with a transverse 
turn around the chest and over both breasts. Both series 
of turns should ascend, and each turn should overlap 
two-thirds of the preceding one (Fig. 78). 



BANDAGES OF THE LOWER EXTREMITY. 



77 



Use. — This bandage is employed to support and com- 
press both breasts and to retain dressings to them. 



Fig. 78. 




Suspensory and compressor bandage of both breasts. 



BANDAGES OF THE LOWER EXTREMITY. 



Single Spica-bandage of the Groin (Ascending). 

Holler Two and a Half Inches in Width, Seven Yards in 
Length. — Place the initial extremity of the bandage upon 
the anterior portion of the right thigh just below the groin, 
and secure it by one or two circular turns around the thigh, 
or place the initial extremity of the roller obliquely upon 
the upper part of the thigh and carry it behind the limb 
and upward around the outer side of the thigh to the abdo- 
men, omitting the circular turns; then carry the bandage 



78 



BANDAGING. 



obliquely across the lower part of the abdomen to a point 
just below the crest of the left ilium, and conduct it trans- 
versely around the back of the pelvis to a corresponding 
point on the opposite side ; then bring it obliquely down- 
ward to the groin and over to the inner portion of the thigh, 
carrying it around the limb, crossing the starting-turn in 
the middle line of the thigh. These turns are repeated, 
each turn ascending and covering in two-thirds of the pre- 
ceding turn, until six or eight complete turns have been 
made, and the bandage is then secured at any point where 
it ends (Fig. 79). This bandage may also be applied by 



Ftg. 79. 




Ascending spica-bandage of the groin. 

placing the initial extremity of the bandage just below the 
anterior superior spinous process of the ilium, and making 
two turns around the pelvis and then carrying the bandage 
to the thigh below the groin, passing it behind the thigh, 
bringing it up on the opposite side of the thigh to cross 
the first turn in the middle line of the groin ; ascending 
spica-turns are then made until a sufficient number have 



BANDAGES OF THE LOWER EXTREMITY. 



79 



been applied to cover in the groin to the desired extent 
(Fig. 80). This bandage possesses the advantage that it 
is less likely to become displaced than the one previously 
described. 

Single Spica-bandage of the Groin (Descending). 
Roller Two and a Half Inches in Width, Seven Yards in 
Length. — Place the initial extremity of the roller obliquely 
upon the anterior surface of the right thigh and secure it 
by one or two circular turns around the limb, or start the 
bandage with an oblique turn, as previously described ; 
then carry the bandage obliquely across the abdomen to 
a point just below the crest of the ilium, and conduct it 
transversely around the back of the pelvis to a correspond- 
ing point on the opposite side ; then bring it obliquely 

Fig. 80. 




Ascending spica-bandage of the groin applied with pelvic turns. 

down over the lower portion of the abdomen,, crossing the 
first turn, to the junction of the thigh with the scrotum, 
pass it under the thigh and bring it up over the lower 
part of the abdomen, and let it follow the course of the first 
turn. These turns are repeated, each turn descending and 
overlapping two-thirds of the preceding turn until the groin 
is covered (Fig. 81). When either of these bandages is 
applied to the left groin, after the initial extremity of the 



80 



BANDAGING. 



roller is fixed, it is carried first to the crest of the ilium 
of the same side, then around the back of the pelvis to a 
corresponding point on the opposite side, then obliquely 
across the lower part of the abdomen to the outer aspect 
of the thigh, being conveyed around this and brought up 
between the thigh and the scrotum, passing obliquely over 
the groin to follow the course of the original turn. This 
bandage may also be applied by making one or two cir- 
cular turns around the pelvis, and the groin is next cov- 
ered in by descending spica-turns. 

Double Spica-bandage of the Groins. Roller Three 
Inches in Width, Nine Yards in Length. — The initial ex- 
tremity of the roller is placed upon the abdomen just above 

Fig. 81. 




Descending spica-bandage of the groin. 

the iliac crests and secured by one or two circular turns : 
the bandage, is then carried from a point just below the 
crest of the right ilium obliquely across the lower por- 
tion of the abdomen to the outer portion of the left 
thigh, is carried around this and brought up between 
the scrotum and the thigh, and is passed obliquely over 
the groin, crossing the previous turn in the median line, 
and is conducted to a point just below the crest of the 
ilium on the same side. The bandage is then continued 



BANDAGES OF THE LOWER EXTREMITY. 



81 



around the pelvis to the same point on the opposite side, 
and from this point is made to pass obliquely over the 
groin to the inner side of the right thigh, passing around 
this and coming up on its outer side, crossing the preceding 
turn at the middle line of the groin, to be carried obliquely 
across the groin and lower part of the abdomen to the 
crest of the ilium on the opposite side. These turns are 
repeated, each turn covering in two-thirds of the previous 
turn, until both groins have been covered (Fig. 82). The 
turns may be so applied as to ascend or descend, forming 
the ascending or descending double spica-bandage of the 

Fig. 82. 




Double spica-bandage of the groins. 

groins. When properly applied, this bandage presents 
three sets of crossing-turns, one in each groin and one in 
the median line of the abdomen. 

Use. — The spica-bandages of the groin, either single or 
double, are employed to hold dressings to wounds in the 
inguinal region — for instance, those resulting from herni- 
otomy, or from operations upon the glands of the groin. 
They are also employed to make pressure upon this region, 
and will often prove of use in the securing of compresses 
applied for the temporary retention of hernise. 
6 



82 



BANDAGING. 



Spica-bandage of Buttock. Roller Two and a Half 

Inches in Width, Seven Yards in Length. — The initial ex- 



Fig. 83. 



Fig. 84. 




m 



m 





Spica-bandage of buttock. 



T-bandage of perineum. 



tremity of the bandage is placed upon the back of the 
thigh just below the gluteal fold, and is carried around 
the thigh and brought back to the posterior aspect of the 
limb, so as to fix and cross the starting-turn near the mid- 
dle of the thigh. It is next conducted obliquely across 
the thigh and buttocks and carried to the brim of the pel- 
vis of the opposite side, when it is brought obliquely 
over the abdomen and back to the posterior surface of the 
thigh. These ascending turns are applied, each turn cov- 
ering in about three-fourths of the preceding one, until the 
buttock is covered, and the bandage is then finished by 
one or two circular turns around the pelvis and abdomen 
(Fig. 83). 

Use. — This bandage is employed to hold dressings to 
the upper posterior portion of the thigh, or the buttock. 



BANDAGES OF THE LOWER EXTREMITY. 



83 



T-Bandage of the Perineum. — This bandage, which 
consists of a strip of muslin three inches in width and 
four feet in length, has pinned or sewed to its centre a 
strip of similar material about forty inches in length. 
The horizontal strip is tied around the abdomen just above 
the pelvis with the attached strip on the lower end of the 
spine ; this strip is brought between the nates and over the 
perineum, and its extremity is split into two tails to a 
point where the scrotum joins the perineum. The tails are 
next carried up on each side of the scrotum and tied to 
the horizontal strip around the abdomen. When used in 
the female the perineal strip need not be split. (Fig. 84). 

Use. — This bandage is employed to hold dressings to 
the anus and perineum. A very satisfactory substitute 
for this bandage consists in the use of a pair of swimming 
tights which may be employed to hold dressings to the 
anus, perineum, or scrotum. 

Fig. 85. 




Figure-of-eight bandage of the knee. 

Figure-of-eight Bandage of the Knee. Roller Two 
and a Half Inches in Width, Five Yards in Length. — The 
initial extremity of the roller is placed upon the left thigh 
three inches above the patella and secured by two or three 
circular turns ; then conduct the bandage over the outer 
condyle of the femur across the popliteal space to the inner 



84 



BANDAGING. 



border of the tibia and around the anterior surface below 
the tubercle and head of the fibula, and make one circular 
turn ; the roller should then be carried obliquely across the 
popliteal space to the inner condyle of the femur, crossing 
the previous turn ; then carry it around the front of the 
thigh to the outer condyle ; repeat these turns, ascending 
toward the knee from the leg and descending from the 
thigh toward the knee, and finish the bandage by a circular 
turn over the patella (Fig. 85). 

This bandage may also be applied by making two circu- 



Fig. 




Figure-of-eight bandage of the knee. 

lar turns around the patella and popliteal space, and then 
carrying the bandage to the thigh three inches above the 
patella, and finishing it with descending turns from the 
thigh and ascending turns from the head of the tibia, mak- 
ing all turns cross in the popliteal space (Fig. 86). 

Use. — This bandage is employed to hold dressings to the 
knee-joint either anteriorly or posteriorly. These figure- 
of-eight turns are often employed in covering the knee in 
applying the spiral reversed bandage of the lower ex- 
tremity when it is desired that the patient be allowed to 
bend the knee. 



BANDAGES OF THE LOWER EXTREMITY. 



85 



Figure-of-eight Bandage of Both Knees. Roller Two 
and a Half Inches in Width, Seven Yards in Length. — Place 
the knees of the patient together with a compress between 
them ; then place the initial extremity of the roller upon 
one thigh, about three inches above the patella, and se- 
cure it by one or two circular turns around both thighs ; 

Fig. 88. 




Figure-of-eight bandages of both knees. 



Complete bandage of the foot. 



then conduct the roller from the outer condyle of the left 
femur obliquely across the popliteal spaces of both legs to 
the head of the fibula on the opposite side, making a cir- 
cular turn around both legs ; pass the roller from the head 
of the fibula on th^ opposite side across the popliteal space 
to the external condyle opposite the point of starting. 

Repeat these turns, descending from the thighs and 
ascending from the legs, until the knees are covered, 
and finish the bandage by carrying a turn of the bandage 
at right angles to the preceding turns between the thighs 
and the legs (Fig. 87). 

Use. — This bandage is employed to secure fixation of 
the limbs after operations upon the perineum, and may also 
be employed to obtain temporary fixation of the limbs in 
transporting cases of fracture of the femur, and after the 
reduction of dislocations of the head of that bone. 



86 



BANDAGING. 



Complete Bandage of the Foot. Roller Two Inches 
in Width, Three Yards in Length. — The initial extremity 
of the bandage is placed upon the sole of the foot near 
the heel, and the foot is covered in by three or four recur- 
rent turns ; these are fixed by one or two circular turns 
around the instep ; the heel is then covered in by a circu- 
lar and figure-of-eight turn, which passes around the 
ankle. The bandage is then carried obliquely over the 
dorsum of the foot to the tip of the toes, when a circular 
turn should be made ; the foot is then covered in by 
ascending spiral reversed turns until the ankle is reached, 
when it is secured by one or two circular turns. This 
bandage may also be applied by first making two or three 
recurrent turns, covering in the toes, the plantar, and dor- 
sal surface of the foot, and the bandage is then completed 
by spiral reversed turns as described above (Fig. 88). 

Spica-bandage of the Foot. Roller Two and a Half 

Fig. 89. 




Spica-bandage of the foot. 



Inches in Width, Five Yards in Length. — Fix the initial 
extremity of the roller upon the ankle and secure it by 
two circular turns ; then carry the bandage obliquely over 



BANDAGES OF THE LOWER EXTREMITY. 87 

the dorsum of the foot to the metatarsophalangeal articu- 
lation, and make a circular turn around the foot at this 
point ; then continue it upward over the metatarsus by 
making two or three spiral reversed turns ; next cany the 
bandage parallel with the inner or outer margin of the sole 
of the foot, according to whether it is applied to the right 
or left foot, directly across the posterior surface of the 
heel ; thence along the opposite border of the foot and 
over the dorsum, crossing the original turn in the median 
line of the foot. This completes the first spica-turn. These 
spica-turns are repeated, gradually ascending by allowing 
each turn to cover in three-fourths of the preceding turn, 
until the foot is covered in with the exception of the pos- 
terior portion of the sole of the heel (Fig. 89). Care should 
be taken to see that the turns cross each other in the median 
line, and that they are kept parallel to each other throughout 
their course. 

Use. — This bandage will be found very useful when 
it is desired to make firm compression upon the foot 
or to retain dressings to it ; it is especially useful in 
the treatment of sprains of the ankle or the anterior 
tarsus. 

Bandage of Foot Covering the Heel (American). 
Holler Two and a Half Inches in Width, Seven Yards in 
Length. — The initial extremity of the roller is placed upon 
the leg just above the malleoli and fixed by two circular 
turns around the leg ; the bandage is then carried obliquely 
across the dorsum of the foot to the metatarso-phalangeal 
articulation, at which point a circular turn is made ; two 
or three spiral or spiral reversed turns are then made, 
ascending the foot; the roller is next carried directly over 
the point of the heel and continued back to the dorsum of 
the foot ; thence beneath the instep around one side of the 
heel and up over the instep ; from this point it is carried 
beneath the instep around the other side of the heel (Fig. 
90), and up in front of the ankle, from which point it may 
be continued up the leg (Fig. 91), 

Use. — This bandage is employed to cover in the foot, 
and retain dressings to the foot and heel. 



88 



BANDAGING. 



Fig. 90. 



Fig. 91. 




Turns covering heel in American bandage. 



Bandage of foot covering the heel. 



Bandage of Foot Not Covering the Heel (French). 

Roller Two and a Half Inches in Width, Seven Yards in 
Length. — Fix the initial extremity of the roller upon the 
leg just above the malleoli and secure it by two circular 



Fig. 93. 



Fig. 92. 




£»i ■ " 



Bandage of foot not covering the heel. 



Bandage of the heel. 



turns around the leg ; the bandage is then carried obliquely 
across the dorsum of the foot to the metatarso-phalangeal 



BANDAGES OF THE LOWER EXTREMITY. 89 

articulation, and at this point a circular turn should be 
made. The roller is now carried up the foot, covering it 
in with two or three spiral reversed turns, and at this 
point a figure-of-eight turn is made around the ankle and 
instep ; this should be repeated once, which will cover in 
the foot with the exception of the heel ; the bandage may 
then be continued up the leg with spiral reversed turns 
(Fig. 92). _ . 

Use. — This bandage may be employed to secure dressings 
to the foot, and is the one generally used to cover this part 
in applying the spiral reversed bandage of the lower 
extremitv. 

Bandage, of the Heel. Roller Two Inches in Width, 
Three Yards in Length. — The initial extremity of the 
bandage is placed over the anterior surface of the ankle 
and is fixed by two circular turns passing over the point 
of the heel. The bandage is then carried obliquely over 
the dorsum of the foot to the tarso-metatarsal articulations, 
at which point a circular turn is made ; the bandage is 
then carried beneath the instep around one side of the heel 
and upward over the instep ; from this point it is carried 
beneath the instep around the other side of the heel. 
Several layers of these turns should be made, and the 
bandage may be finished by a circular turn around the 
leg just above the ankle (Fig. 93). 

Use. — This bandage may be employed to retain dress- 
ings to the heel. 

Spiral Reversed Bandage of the Lower Extremity. 
Holler Two and a Half Inches in Width, Seven Yards in 
Length. — The initial extremity of the roller is placed 
upon the leg just above the malleoli and secured by 
two circular turns. It is then carried obliquely over 
the foot to the metatarso-phalangeal articulation, where 
a circular turn is made around the foot. Two or three 
spiral reversed and two figure-of-eight turns of the 
ankle and instep should be made, while just above the 
ankle one or two circular or spiral turns are made around 
the leg, and as the bandage is carried up the leg, as it 
increases in diameter, spiral reversed turns are made until 
it approaches the knee ; at this point, if the limb is to be 



90 BANDAGING. 

kept straight, the spiral reversed turns may be continued 
over this region and up upon the thigh. If the knee is 
to be bent, figure-of-eight turns may be applied until the 
knee is covered, and then the thigh may be covered with 
spiral reversed turns (Fig. 94). To cover in the thigh as 

Fig. 94. 




Spiral reversed bandage of the lower extremity. 

well as the leg, two bandages of the dimensions before 
given will be required. Care should be taken to keep 
the reverses in a line, and not to make them over the 
spine of the tibia, as they may thus become painful to 
the patient. 

Use. — This is one of the most frequently employed of 
the roller-bandages ; it is used to apply pressure to the 
lower extremity, to retain dressings, and to secure splints in 
the treatment of fractures and dislocations. 

Spiral Reversed Bandage of the Thigh. Roller 
Three Inches in Width, Six Yards in Length. — The initial 
extremity of the bandage is secured around the thigh just 
above the knee-joint by two or three circular turns, and 
the bandage is carried up the thigh by spiral reversed 
turns until the groin has been reached, when it is secured 
by one or two circular turns around the thigh. Care 
should be taken that it is not applied too firmly, that the 
superficial veins are not obstructed, causing swelling of the 
leg below the knee (Fig. 95). 

Use. — This bandage is employed to retain dressings or 
splints to the thigh. 



BANDAGES OF THE LOWER EXTREMITY. 



91 



Figure-of-eight Bandage of the Leg. Roller Two and 
a Half Inches in Width, Seven Yards in Length. — This 
bandage differs from the spiral reversed bandages of the 



Fig. 95. 




Spiral reversed bandage of the thigh. 



lower extremity only in the fact that when the swell of 
the calf is reached figure-of-eight turns are made around 



Fig. 96. 




Figure-of-eight bandage of the leg 



92 BANDAGING. 

the leg instead of spiral reversed turns. In applying the 
roller, when the calf of the leg is reached the bandage is 
carried obliquely around the leg to the crest of the tibia 
- and then made to cross the starting-turn in the median 
line ; these descending and ascending turns are repeated 
until the calf of the leg has been covered in, and the band- 
age is finished with one or two circular turns just below 
the knee (Fig. 96). 

Use. — This bandage holds its place more firmly than 
the ordinary spiral reversed bandage of the leg, and may 
be employed in the treatment of ulcers of the leg in con- 
junction with strapping, where it is desirable to change the 
dressings at infrequent intervals and to allow the patient 
to walk about during the course of treatment. 

SPECIAL BANDAGES. 

Spiral Reversed Bandage of the Penis. Roller Three- 
quarters of an Inch in Width, Thirty Inches in Length. — 
Fix the initial extremity of the roller by two circular 
turns around the penis close to the pubis ; then carry the 
bandage obliquely down to the corona glandis ; from this 
point ascend the body of the penis by spiral reversed turns 
to the pubis, and finish the bandage by two figure-of-eight 
turns around the neck of the scrotum and root of the 
penis, or split the end of the bandage so as to form two 
tails, and secure it by tying these around the root of the 
penis (Fig. 97). 

Bandage of Perineum. — To hold dressing to the peri- 
neum or anal region a single T-bandage is usually em- 
ployed. (Fig. 84). To secure dressings to this region 
the use of swimming tights will be found very satisfac- 
tory in holding the dressings in place if the patient is com- 
pelled to be on his feet (Fig. 98). 

Recurrent Bandage of a Stump. Boiler Two and a 
Half Inches in Width, Five to Seven Yards in Length. 
— Place the initial extremity of the roller upon the ante- 
rior or posterior surface of the limb a few inches above the 



SPECIAL BANDAGES. 



93 



extremity of the stump, and carry the bandage to the end 
of the stump, and then conduct it upward or downward 
on the limb, as the case may be, to a point directly oppo- 
site the point of starting ; then bring the bandage back 



Fig. 97. 




Fig. 98. 




Spiral reversed bandage of the penis. 



Swimming tights employed to se- 
cure dressing to perineum or anal 
region or groin. 



over the face of the stump to the point of starting, and 
continue these recurrent turns, each turn overlapping two- 
thirds of the preceding one, until the face. of the stump is 
covered ; then reverse the bandage and secure the recur- 
rent turns at their points of origin by two or three circular 
turns. The roller should next be carried obliquely down to 
the end of the stump, and a circular turn should be made 
around this. The bandage should then be carried up the 
limb by spiral or spiral reversed turns beyond the point at 
which the recurrent turns terminated, and secured by one 
or two circular turns (Fig. 99). 

In applying this bandage to very short stumps result- 
ing from amputations at or near the shoulder- or hip-joint, 
after making the recurrent and spiral turns, it will be 



94 



BANDAGING. 



found necessary to carry the bandage, in the case of am- 
putations of the shoulder, across the chest to the opposite 
axilla and back, and apply several of these turns ; so in 
case of hip amputations it will be found best to finish the 
bandage with a few turns about the pelvis. 



Fig. 99. 




Recurrent bandage of a stump. 

Bandage for Securing* the Hands and Feet in the 
Lithotomy Position. — The hand of the patient should be 
brought down and made to grasp the outer side of the 
foot ; the initial extremity of the roller is fixed by two 
circular turns around the wrist and ankle, and the bandage 
is then passed around the foot and hand, and these turns 
are alternated with turns around the wrist and ankle until 
the hand and foot are firmly secured. The same proced- 
ure is adopted with the hand and foot of the opposite side 
Fig. 100. 

Liebreich's Eye-bandage. — This bandage consists of 
a strip of flannel two and a half inches in width and from 
six to ten inches in length, to the extremities of which 
tapes are sewed. It may be applied transversely so as to 
cover both eyes, or obliquely so as to cover only one eye ; 
it is secured by the tapes carried around the head and tied 
over the forehead (Fig. 101). 



SPECIAL BANDAGES. 



95 



Use. — This bandage is used to hold compressed or 
dressings to the eye or eyes ; the elasticity of the flannel 
permits of its being applied so as to make a variable 
amount of pressure. 

Borsch's Eye-bandage. — This bandage is employed for 
holding a dressing to one eye, and consists in a strip of 
flannel, two or two and a half inches in width, which is 
passed around the head from the occiput and covers both 



Fig. 100. 



Fig. 101. 





Bandage for securing the hands 
and feet for lithotomy. 



Liebreich's eye-bandage. 



eyes (Fig. 102). A narrow strip of flannel is attached to 
the posterior portion, which is carried over the head and 
passed under the horizontal strip in front of the eye which 
is to be left uncovered, and is then folded back so as to raise 
the horizontal strip from the eye, and secured (Fig. 103). 
Bandages of ScultetUS. — This is a compound bandage, 
consisting of a number of pieces of muslin, and may be 
prepared from a two and a half or three inch roller by 
cutting off strips sufficiently long to encircle the part about 
one and one-third times. The strips are placed under the 



96 B AS D AGING. 

part in such a manner that the first piece shall be over- 
lapped by the second, the second by the third, and so on 
from below upward ; the pieces are then brought around 
the limb, and the extremities of the last piece are secured 
by pins (Fig. 104). This bandage was formerly much em- 
ployed in the treatment of compound fractures to secure 
dressings to the wound, and possessed the advantage that 

Fig. 102. FiG. 103. 





Amplication of Borsch's eye-bandage. 

when a single strip became soiled it could be removed with- 
out disturbing the whole dressing, the new strip to be in- 
troduced being pinned to the extremity of the soiled piece 
to be removed, and then being drawn through by its re- 
moval. This bandage will often be found convenient in 
applying dressings to cases of excision of the joints, where 
as little disturbance of the parts as possible is important 
in dressing the wound. AYhen the strips are attached to 
each other by a thread passed through the centre of each 
strip, the bandage is known as Pott's bandage. It is 
applied and secured in the same manner, but it possesses 
no advantages over the bandage of Scultetus. 

Gauze Bandages. — Bandages may be prepared from 
gauze, the same material that is used for gauze dressings, 
and are now very extensively used in surgical practice. 



SPECIAL BANDAGES. 



97 



The gauze bandages are prepared by cutting or tearing 
the material into strips varying in width from two inches 
to three inches, and in length from five yards to eight 
yards ; these strips are then wound so as to form roller- 
bandages. Gauze bandages are sometimes employed in 
the dressing of fractures, but do not furnish as substantial 
a dressing as the ordinary muslin bandages. They, how- 

Fig. 104. 




Bandage of Scultetus. 

ever, constitute a soft and comfortable material for hold- 
ing dressings to wounds. They are applied in the same 
manner as the ordinary muslin roller, with the exception 
that in their application reverses are seldom required, as 
the open mesh of the bandage gives it considerable elas- 
ticity, so that the bandage can be made to adapt itself to 
the part without making reverses. Any of the ordinary 
bandages which have been previously described may be 
applied by means of the gauze bandages, such as those of 
the head, extremities, and trunk. 

Gauze Bandage of Head and Neck. — In applying dress- 
ings to wounds of the head and neck, it is advisable to 
cover in both the head and neck, and also to make a few 
turns over the upper part of the chest and around each 
7 



98 



BANDAGING. 



shoulder, which prevents the turns of the bandage from 
slipping and holds the dressing in place, so that it cannot 
be disarranged by movements of the patient (Fig. 105). 

Gauze Bandage of Upper Extremity. — The initial ex- 
tremity of the bandage is secured by two or three turns 
around the wrist, and the bandage is then carried obliquely 
over the dorsum of the hand to the tip of the little finger, 

Fig. 105. 





Gauze bandage of head and neck. 



when a circular turn is made ; the hand is then covered in 
by circular turns. The region of the wrist is next covered 
by figure-of-eight turns and the bandage is carried up the 
forearm by circular turns. Figure-of-eight turns are made 
at the elbow and the bandage is continued with circular 
turns around the arm. No reverses need be made in ap- 
plying this bandage. 



SPECIAL BANDAGES. 



99 



Use. — This bandage is used for the same purposes as the 
spiral reversed bandage of the upper extremity. 

Gauze Bandage of Chest and Shoulder. — In applying this 
bandage, a gauze roller, three or four inches in width, is 
employed. The initial extremity of the bandage is secured 
around the lower portion of the chest by one or two turns 
and it is carried up to the axillary lines by circular turns ; 
at this point it is secured obliquely across the chest to the 
base of the neck and then behind the shoulder to the pos- 
terior portion of the axilla. From this point the turn is 

Fig. 106. 




Gauze bandage of chest and shoulder. 



carried through the axilla and over the shoulder and is con- 
ducted over the back of the chest to the posterior aspect 
of the opposite axilla, through which it passes to be carried 
over the anterior portion of the chest and shoulder to the 
opposite axilla. Then turns are repeated until a dressing 
of sufficient firmness is applied (Fig. 106). This bandage 
is used to secure dressings to the chest, axilla, and shoulder. 
Flannel Bandage. — These bandages are prepared from 
flannel, which is cut into strips from two to four inches in 
width and from five to seven yards in length. These 



100 BANDAGING. 

strips are formed into rollers either by hand or by means 
of the bandage- winder. Flannel bandages, by reason of 
the elasticity which they possess, can be applied without 







Fig. 107. 








^ 










ir JmP 


r^ fl'.'Vv'' H 1 


BWteBWMS 

■BngHKB 




1 








. ^y^ 



Black muslin bandage of hand and arm. 

reverses, and are used to make a moderate amount of elastic 
pressure. They are often employed in applying dressings 

Fig. 108. 




Black muslin bandage of the hand. 



to the head, especially after operations upon the eyes, and 
are generally applied as a primary roller before the appli- 



SPECIAL BANDAGES. 



101 



Fig. 109. 



cation of plaster-of-Paris dressings, and may also be used 
in subacute joint-affections, both to protect the parts and 
to make a moderate amount of elastic pressure. 

Black Muslin Bandages. — From the fact that dark- 
colored bandages are less conspicuous than white ones,, 
they are sometimes prepared from black or brown muslin. 
They are applied iu the same manner as the ordinary mus- 
lin or gauze bandage. For this reason they may be used 
for bandages of the head, hand, or arm in patients who 
are treated as walking cases, and who object to the con- 
spicuousness of a white bandage (Figs. 107, 108 and 109). 

The Rubber Bandage. — This bandage, which was in- 
troduced to the profession by Dr. Martin, of Boston, is 
made from a strip of rubber-sheeting, from one inch to 
four inches in width and from three to live yards in 
length, which, for 
convenience of ap- 
plication, is rolled 
into a cylinder. It 
will be found a use- 
ful form of dressing 
where it is consid- 
ered desirable to ap- 
ply elastic pressure 
to a part (Fig. 110). 

It may be em- 
ployed in the treat- 
ment of varicose 
veins of the legs, in 
chronic ulcers of 
those parts where 
pressure is an im- 
portant element in 
the treatment, and 
may be used as a sub- 
stitute for strapping to secure this object. Its application has 
also been recommended in the treatment of swelled testicle in 
that stage of the affection in which pressure is indicated. 




Black muslin bandage of head. 



102 



BANDAGING. 



Ftg.110. 



For applicatin to the leg, a rubber bandage two and a 
half inches in width and three yards in length is required. 
The initial extremity of the roller is fixed upon the foot 
near the toes and secured by a circular turn ; the foot is 
then covered in by spiral turns overlapping each other 
about two-thirds, and a figure-of-eight turn is made from 
the ankle to the instep. The bandage is then carried up 
the limb to the knee with spiral turns, where it is secured 
by two tapes sewed to the terminal extremity of the band- 
age, which are passed around the leg and tied. The band- 
nge need not be reversed, as its elasticity allows it to con- 
form to the shape of the limb. Care should be taken not 
to apply the turns with too much firmness ; the bandage 
should be stretched very slightly ; if this precaution is 

not taken, it soon be- 
comes uncomfortable 
to the patient. A pa- 
tient using one of these 
bandages will soon 
learn to apply it him- 
self, making just the 
requisite amount of 
tension to secure its 
holding its place, and 
to insure a comfortable 
degree of pressure upon the part. A well-fitting stocking 
may be placed upon the limb before the bandage is ap- 
plied, or it may be applied directly to the skin. 

The bandage should be removed at night when the 
patient goes to bed and hung up to dry, as its inner sur- 
face becomes moist from the secretions from the skin ; it 
should be reapplied as soon as the patient rises in the 
morning. 

In using it in the treatment of ulcers of the leg no oint- 
ment should be applied to the ulcer, as oily dressings soon 
destroy the rubber ; applications may be made to the ulcer 
by means of dry powders, such as oxide of zinc, iodoform, 
or aristol, before the bandage is applied. 

In the treatment of swelled testicle the bandage is ap- 




Martin's rubber bandage. 



SPECIAL BANDAGES. 103 

plied to the testicle by means of recurrent turns not toe 
firmly made, and secured in place by spiral turns, until the 
whole surface of the organ is covered in ; the end of the 
bandage is secured with tapes tied around the root of the 
scrotum. The same precaution to apply the bandage so 
as to make only moderate pressure should also be observed 
here. 

Elastic-webbing' Bandage. — This bandage, which is 
woven from threads of rubber covered with cotton or silk, 
has recently been introduced, and possesses all the advan- 
tages of the rubber bandage as regards elasticity, and has 
the additional advantage that air can circulate through the 
meshes of the bandage and moisture can evaporate from 
the surface covered by the bandage, so that the skin cov- 
ered by it does not become bathed in perspiration, as is 
the case with the rubber bandage. It is applied in the 
same manner and for the same purposes as the rubber 

Fig. 111. 




Elastic webbing bandage applied to leg. 

bandage (Fig. 111). The patient soon learns to apply it 
himself, so as to make the requisite amount of pressure. 
In the treatment of varicose veins and oedema of the legs 
we have found it a most satisfactory dressing. 



104 BANDAGING. 



FIXED DRESSINGS, OR HARDENING BANDAGES. 

For the application of these dressings a variety of 
substances are used which are incorporated in the meshes 
of some fabric, such as crinoline or cheese-cloth, or painted 
over its surface to give fixity or solidity to the bandage. 

The materials most commonly used in the preparation 
of fixed dressings are plaster-of- Paris, starch, silicate of 
sodium or potassium, and paraffin. 

Plaster-of-Paris Dressings. 

The plaster-of- Paris used for the application of surgical 
dressings should be of the same quality as that which 
dental surgeons employ in taking casts for teeth — that is, 
the extra-calcined variety. If moist or of inferior quality, 
it will not set rapidly or firmly, and will fail to give suffi- 
cient fixation to the dressing. 

Methods of Applying Plaster-of-Paris Dressings. — 
The plaster-of-Paris dressing may be applied in several 
ways, either by covering the part to be enclosed with some 
loose fabric, and rubbing the moist plaster into it, alter- 
nating the layers of the fabric with layers of moist plaster, 
or it may be applied by means of a roller which has been 
prepared by incorporating plaster-of-Paris in its meshes. 

It may also be applied in the form of the Bavarian 
dressing (page 112), or in the form of moulded plaster-of- 
Paris splints (page 113). . 

To apply a plaster-of-Paris dressing according to the first 
method, the part to be enclosed — the leg, for instance — 
should first be covered by a neatly applied flannel bandage, 
or a muslin bandage which has been shrunken by being 
washed ; new muslin is not satisfactory as a primary appli- 
cation to a limb in applying a plaster-of-Paris dressing, as 
the moisture from the plaster wets it and causes it to 
shrink, so that it may exert injurious pressure after the 
bandage becomes dry. 

The limb having been covered by the bandage, and any 



FIXED DRESSINGS, OR HARDENING BANDAGES. 105 

bony prominences, such as the malleoli, having been 
padded with small wads of cotton to prevent undue 
pressure upon them, the part is next covered by a layer 
of turns of a crinoline bandage or by strips of cheese- 
cloth or any other loose material. A small quantity of 
plaster-of-Paris is next mixed with water until it has the 
consistence of thick cream, when it is smeared evenly 
over the whole surface of the previously applied bandage. 
Another layer of the bandage or of strips is next applied, 
and the plaster is smeared over this in the same manner, 
and so alternate layers of plaster-of-Paris and bandage are 
applied until a casing of the desired thickness is obtained. 
If plaster-of-Paris of the quality previously described be 
used, it will set or become hard in a few minutes. 

The most convenient method of applying the plaster- 
of-Paris dressing is that introduced by the late Professor 
Sayre, which consists in the use of bandages which have 
been previously prepared with plaster-of-Paris ; these 
are moistened and applied while moist to the part to be 
encased. 

Preparation of Plaster-of-Paris Bandages. — These 
bandages are prepared by taking cheese-cloth, mosquito- 
netting, or crinoline, which latter is by far the best 
fabric, and cutting or tearing it into strips two and a half 
to three inches in width and five yards in length. These 
are laid on a table, and plaster-of-Paris of the quality 
before mentioned is dusted over them and rubbed into the 
meshes of the fabric ; the material when impregnated with 
plaster is loosely rolled into a cylinder, and these band- 
ages when prepared should be placed in air-tight jars or 
tin cans until required. 

Bandages thus prepared, which have been exposed to 
the air or have been kept for a long time, are not apt to 
set well when applied ; but if such bandages are placed 
in a hot oven and baked for half an hour before being 
used, they will be found to set as satisfactorily as those 
freshly prepared. 

These bandages may be prepared by a machine made 
for this purpose; but I do not think that they are apt to 
have the plaster as evenly distributed through them, and, 



10 6 BANDAGING. 

therefore, are not as satisfactory as those prepared by 
hand. 
Application of the Plaster-of-Paris Bandage.— Before 

applying this dressing, the part to be encased — the leg, for 
instance — should be covered by a flannel roller, the bony 
prominences being protected by pads of cotton, or a 
closely fitting stocking may be applied to the part. Cotton 
wadding cut into strips of the desired width and formed 
into a roller may be used instead of the flannel roller. 

The bandage should be dipped in warm water and kept 
completely immersed for a few minutes ; it should then be 
squeezed with the hand, and as soon as bubbles of air 
cease to escape it is a sign that it is thoroughly soaked 

Fig. 112. 




Leg encased in plaster-of-Paris dressing. 

and is ready for application. On removing it from the 
water the excess of water should be squeezed out by the 
hand, and the bandage should then be applied evenly to 
the limb with just sufficient firmness to make it fit the 
part nicely, and as few reverses as possible should be 
made. A sufficient number of bandages are applied to 
make a dressing as firm as may be required ; three rollers 
of the above dimensions are usually ample for a dressing 
for the leg, and when the last roller has been applied dry 
plaster should be moistened with water until it has the 
consistency of thick cream, and rubbed evenly over the 



FIXED DRESSINGS, OR HARDENING BANDAGES. 107 

surface of the bandage to give it a finish (Fig. 112). If a 
good quality of plaster has been used, the bandage should 
be quite firm in from ten to fifteen minutes, but the patient 
should not for a few hours be allowed to bear any weight 
upon the bandage. 

An equally firm dressing may be applied with the use 
of a less number of bandages, if the surgeon rubs over 
the surface of each layer of bandage applied a little moist 
plaster, then applying another layer and repeating the 
procedure ; finishing the dressing by an external coating 
of moist plaster, as above described. 

In applying these dressings a fewer number of band- 
ages will be required if narrow strips of tin, zinc, or 
binders' board are incorporated in the layers of the band- 
age, which increase the strength of the dressing. 

Application of the Plaster-of-Paris Bandage to the 
Thigh and Pelvis. — Where it is desirable to apply a 

Fig. 113. 




Pelvic supporter. 

plaster-of-Paris bandage to the thigh, and at the same 
time fix the hip-joint by including the pelvis in the band- 
age, the use of a pelvic supporter (Fig. 113) is most satis- 
factory. The patient is placed upon the supporter so that 
the lumbar spine rests upon the body of the supporter, 
while the pelvis rests upon the metal shelf which extends 
from it, as seen in Fig. 114. The limb is extended and 
held in the required position, and the plaster bandage is 
applied to the thigh, and is also carried around the pelvis 
and passed over the metal shelf upon which the pelvis 



108 



BANDAGING. 



rests. When the bandage has become firm, the supporter 
is removed by slipping it upward. 



Fig. 114. 




Position of patient upon pelvic supporter. 

Interrupted Plaster-of-Paris Dressing. — This form 
of plaster-of- Paris dressing is applied by first placing a 
short iron rod under the extremity, opposite to and extend- 
ing some distance above and below the point at which the 




Interrupted plaster-of-Paris dressing. (Stimson.) 

dressing is to be interrupted ; this is fixed by a few turns 
of the plaster bandage above and below the portion of 
the limb which is to be left exposed ; stout wire is next 
bent into loops, the extremities of which are incorporated 
in the subsequent turns of the plaster bandage ; three 
loops thus placed in addition to the posterior iron bar 



FIXED DRESSINGS, OR HARDENING BANDAGES. 109 

will usually make the dressing sufficiently firm (Fig. 115). 
A. number of turns of the bandage are applied to fix the 
metal loops firmly, and the limb is held in the desired 
position until the plaster has set. 

Application of the Plaster-of-Paris Jacket. — The 
patient's body should be covered with a soft, closely 
fitting woven shirt without arms, but with shoulder-straps 
to hold it in position, or an ordinary woven undershirt may 
be employed ; one or two folded towels, or a pad of cotton 
wrapped in a towel, are next placed over the abdomen 
between the shirt and the skin — this was called, by Pro- 
fessor Sayre, the dinner pad, and is intended to leave space 
for distention of the abdomen after eating. Small pads of 
raw cotton may also be placed over the anterior iliac spines, 
and, in the case of females, a pad of cotton wrapped in a 
handkerchief may be placed over each mammary gland. 

The patient should next be suspended by the apparatus, 
consisting of a collar and arm-pieces attached to a cross- 
bar (Fig. 116), which is attached by a cord and pulley to a 
tripod. If this apparatus is not at hand, a very satisfac- 
tory substitute may be made by folding two towels into 
cravats and tying together the ends, so as to make two 
loops, one of which is placed in each axilla ; a bar of wood 
two and a half feet in length is next taken, and the loops 
are secured to the ends of this by stout cords or handker- 
chiefs ; a Barton's bandage is next applied to the head, and 
a strip of bandage is passed under the turns wdiich cross 
the vertex and is secured to the middle of the cross-bar. 
The bar is next suspended by a cord passed through a 
pulley or ring, which may be attached to the top frame of 
a door if the ordinary tripod cannot be obtained. 

The patient should be raised slowly by the apparatus 
until the toes only are in contact with the floor, and the ex- 
tension should not be carried to the point which makes it 
uncomfortable to the patient (Fig. 117). The shirt should 
be drawn downward over the hips by an assistant and held 
in place until a few turns of the bandage have been applied. 

The plaster-bandage having been soaked and squeezed, 
a turn should be made around the body above the pelvis, 
and it should then be carried downward below the iliac 



110 



BANDAGING. 



spines, and from this point made to ascend gradually 
by spiral turns until it reaches the axillary line. The 
turns should be applied smoothly and not too tightly. 
After two or three layers of turns have been applied, the 
surgeon may rub some moist plaster upon their surface if 



Fig. 116. 



Fig. 117. 




Suspensory apparatus. 



Patient suspended for application of 
plaster jacket. 



he desires to use fewer bandages. These turns are repeated 
until a bandage of the desired thickness is applied, and the 
surface of the dressing may be finished by rubbing it over 
with moistened plaster. This jacket for a child will gen- 
erally require the use of three or four bandages of the 
dimensions given ; for an adult, from six to eight bandages. 



FIXED DRESSINGS, OR HARDENING BANDAGES. Ill 

The patient should be kept suspended until the bandage 
has set, usually from ten to fifteen minutes, and then should 
be lifted carefully so as not to bend the spine, and placed 
on his back upon a mattress, until the dressing becomes 
perfectly hardened. The dinner pad and mammary pads, 

Fig. 118. 




Application of plaster jacket in the recumbent posture. (Lovett.) 

if they have been used, should next be removed. In 
applying this dressing, strips of zinc or tin may be placed 
between the layers of bandage if it is desired to give more 
strength to the jacket. 

Fig. 119. 






Frame for the application of plaster jacket in the recumbent posture. (Lovett.) 

The plaster jacket may also be applied in the recumbent 
posture, the patient being placed upon a frame (Figs. 118 

and 119). 

Application of the Jury-mast by Means of Plaster- 
of-Paris. — In disease of the spine involving the cervical 
or upper dorsal region the ordinary plaster-of-Paris jacket 



112 



B AS D AGING. 



Fig. 120. 



is not satisfactory, and in such 
cases the " jury-mast " is employed 
in connection with the plaster 
jacket. In applying the "jury- 
mast," the same steps are taken in 
the preparation of the patient as 
in applying the plaster-of-Paris 
jacket, with the exception of ex- 
tension, which need not be used. 

After three or four layers of the 
plaster-bandage have been applied 
to the body, an apparatus made of 
two bars of metal having two per- 
forated strips of zinc attached to 
them a few inches apart, which 
partly encircle the body, is applied 
and held in position by turns of 
the plaster-bandage. The perpen- 
dicular bars have at their upper 
part a slot, into which the lower 
end of the "jury-mast" fits, and 
is secured by a. screw ; to the upper 
part of this is attached a movable 
cross-bar, to which are fastened the straps of the collar 
from which the head is suspended (Fig. 120). 

The Bavarian Dressing. — To apply this dressing, 
which is sometimes employed in the treatment of fractures 
of the extremities, take two pieces of Canton flannel the 
length of the part to be enclosed, and more than wide 
enough to envelop its circumference. In applying it to 
tiie leg, these pieces should be cut so as to correspond to 
the outline of the leg and posterior portion of the foot. 
These pieces should be placed one over the other and 
sewed together in the middle line, the seam corresponding 
to the back of the leg. This dressing is then placed under 
the foot and leg, and the inner layer of flannel is brought 
up in front of the leg and over the dorsum of the foot, and 
made fast with pins or a few stitches (Fig. 121). Plaster- 
of-Paris is next mixed with water to form a paste,, which 




Head-support and jury-mast. 



FIXED DRESSINGS, OR HARDENING BANDAGES. 113 

is rubbed thickly and evenly over the flannel next the 
limb until a sufficient thickness is obtained ; the outer 
layer of flannel is then brought up about the leg and 
moulded to its surface by the hands. A loosely applied 
roller may be used to hold the dressing in place until the 
plaster has set. 

When it is necessary to inspect the parts, the turns of 
the bandage are cut, and upon separating the layers of 
flannel the two halves can be turned aside, the seam at the 
back acting as a hinge. Upon reapplying the splints to 

Fig. 121. 




Bavarian dressing. 



the leg they may be retained in position by a roller or by 
one or two strips of bandage. 

Moulded Plaster Splints. — It is sometimes found diffi- 
cult to apply the ordinary plaster dressings to parts irreg- 
ular in shape, and at the same time to have a splint which 
can be removed with ease. To accomplish this purpose, 
moulded splints of plaster may be made by cutting a 
paper pattern of the part to be covered in, and then cutting 
pieces of crinoline to conform to this pattern ; eight or ten 
pieces will usually form a splint of sufficient thickness. 
One of these pieces of crinoline is laid upon a table and 
dry plaster is rubbed into its meshes ; another is laid 



114 BANDAGING. 

upon this and plaster is applied to it in the same way, 
and so on until all the pieces have been placed in posi- 
tion, one over the other, with plaster rubbed well into 
the meshes. The dressing is then folded up and dipped 
into water, squeezed out, and moulded to the part and held 
in position, until it sets, by the turns of a bandage. The 
edges should overlap slightly, and in applying it a strip of 
waxed paper may be placed under the overlapping edge to 
prevent its adhesion to the dressing below, and thus facili- 
tate its removal. Splints prepared in this way can be re- 
moved with ease, and are often of service in cases where 
it is desirable to inspect the parts frequently. I have em- 
ployed with advantage such splints in making fixation of 
the hip-joint in cases of coxalgia, and also for the same 
purpose in diseases of other joints. The splints upon 
being reapplied are secured by a few strips of adhesive 
plaster or by a roller-bandage. 

Trapping Plaster-of-Paris Bandages. — In applying 
the plaster-of-Paris dressing to a part where there is a 
wound which is covered by the plaster-bandage, it is well 
to make some provision whereby the plaster dressing over 
the site of the wound may be cut away, making a trap or 
window through which the wound may be inspected, or 
dressed if necessary (Fig. 122). To accomplish this, be- 
fore applying the plaster-bandage, a compress of lint or 
gauze or a small pasteboard box should be placed over 
the wound, which, when the dressing is completed, forms 
a projection on its surface, indicating the position of the 
wound, and also allows the surgeon to cut away the dress- 
ing without injuring the skin below. These traps may be 
cut out after the bandage has partially set, or after it has 
become hard. In applying the plaster-of-Paris dressing 
in cases of compound fracture, I always make provision 
for trapping of the bandage if it should become necessary, 
although in the vast majority of cases if the wound re- 
main aseptic it does not have to be done. 

Removing Plaster-of-Paris from the Hands. — One 
objection to the use of plaster-of-Paris dressings is the 
difficulty of removing it from the hands of the surgeon, 



FIXED DRESSINGS, OR HARDENING BANDAGES. 115 

and the harsh condition in which the skin is left after its 
removal. If, however, the hands are washed in a solu- 
tion of carbonate of sodium — a tablespoonful to a basin 
of water — the plaster will readily be removed and the 
skin will be left in a soft and comfortable condition. Rub- 
bing the hands with glycerine, moist brown sugar or corn- 
meal accomplishes the same object. 

Fig. 122. 




Plaster-of-Paris bandage trapped. 



Removal of the Plaster-of-Paris Bandage. — The 

removal of the plaster-bandage is sometimes a matter of 
difficulty particularly, in the case of fractures, if it has to 
be removed before the fragments below it are consoli- 
dated, as it may disarrange them and cause the patient 
pain if it is not accomplished without much force. 

When the bandage is applied to get a cast of a part, or 
in the treatment of fractures where it may be necessary to 
remove the bandage in a few days to inspect the parts, a 
strip of sheet-lead one-half of an inch in width is first 
placed over the flannel bandage and is allowed to project 
at each end beyond the dressing ; the plaster can then be 



116 BANDAGING. 

readily cut through upon the strip of lead with a knife 
without injury to the parts below (Fig. 1 23). As soon as the 

Fig. 123. 




Cutting plaster-bandage upon lead « + ,rip. 

bandage has become firm, the lead strip is removed by trac- 
tion upon one end of it ; and, if the bandage has been entirely 
divided, it can be removed at any time without difficulty. 
In applying plaster dressings to the extremities, even 
if their removal is not likely to be immediately required, 
I usually employ the lead strip, cutting the bandage upon 
\t, but leaving three or four bridges of undivided band- 

Fig. 124. 




Hunter's saw for removing plaster bandages. 

age, which can easily be divided when the removal of the 
bandage is finally required. 

Plaster-bandages may also be removed by means of a 
saw devised for this purpose (Fig. 124) ; by Gigli's wire 
saw drawn under the bandage by a string, which cuts 



FIXED DRESSINGS, OR HARDENING BANDAGES. 117 

rapidly and does not endanger the skin ; by strong cutting- 
shears of various kinds (Fig. 125) ; or a line may be painted 
over the dressing with hydrochloric acid or vinegar, which 
softens the plaster, so that it can readily be cut through 
with a knife. The incision of the bandage upon the lead 
strip or the use of the saw or shears is, I think, most 
satisfactory in removing these dressings. They should 

Fig. 125. 



Shears for cutting plaster-bandages. 

be used carefully, as the final layers of the bandage are 
divided, to avoid wounding the skin. 

Uses of Plaster-of-Paris Dressings. — These dressings 
are employed to secure fixation as primary or secondary 
dressings in the treatment of fractures, and in the ambu- 
lant treatment of fractures, and for a like purpose in 
injuries and diseases of the joints. They are also largely 
employed in the treatment of diseases and deformities of 
the spinal column, and will be found most satisfactory 
applications after osteotomy and tenotomy, to secure im- 
mobility and to hold the parts in their corrected positions ; 
when employed in the dressing of cases after tenotomy, 
I hey are generally used for a few weeks until the appro- 
priate mechanical apparatus is applied. 

The Starched Bandage. — To apply this bandage, 
starch is first mixed with cold water until a thin, creamy 
mixture results, and this is heated until it is converted into 
a clear mucilaginous liquid. The part to be dressed is first 
covered with a flannel roller, and over this a few layers 
of a cheese-cloth or crinoline bandage, which has been 
shrunken, are applied ; the starch is then smeared or 



118 BANDAGING. 

rubbed with the hand evenly into the meshes of the mate- 
rial, and the part is again covered with a layer of turns 
of the bandage, and the starch is again applied ; this 
manipulation is continued until a dressing of the desired 
thickness is produced. Strips of pasteboard may be 
applied between the layers of the bandage, to give addi- 
tional strength to the dressing, if desired. 

It requires from twenty-four to thirty-six hours for the 
starched bandage to become dry and thoroughly set. It 
may be removed in the same way in which the plaster-of- 
Paris dressing is removed. 

Use. — Before the introduction of the plaster-of-Paris 
dressing, it was frequently employed in the treatment of 
fractures, and in injuries and diseases of the joints. It 
may be used in such cases, but possesses no advantage 
over the plaster-of-Paris dressing, and has the disadvan- 
tage of setting much less promptly. 

Silicate of Potassium or Sodium Bandage. — In 
applying this bandage, after a flannel roller and several 
layers of a cheese-cloth or crinoline bandage have been 
applied to the part, the surface of the latter is coated with 
silicate of sodium or potassium applied by means of a 
brush, then a second layer of bandage is applied and 
treated in the same manner, and this manipulation is con- 
tinued until a bandage of the desired thickness is pro- 
duced. This dressing may also be applied by soaking 
loosely wound rollers of crinoline in silicate of potassium 
or sodium and applying them to the part as the plaster-of- 
Paris bandage is applied. It requires twenty-four hours 
for this dressing to become firm. As it is irksome for a 
patient to keep a part quiet while the silicate bandage is 
becoming firm, I often cover it as soon as applied with a 
layer of tissue-paper, and apply over it a light plaster-of- 
Paris bandage, which sets in a few minutes ; this is removed 
at the end of twenty-four hours, when the silicate bandage is 
usually firm. In removing the silicate bandage, it may first 
be softened by soaking it in warm water, and then it can read- 
ily be cut with scissors, or it may be cut with bandage-shears. 



FIXED DRESSINGS, OR HARDENING BANDAGES. 119 

In applying either the starched bandage or the silicate of 
potassium bandage, care should be taken to use cheese-cloth 
or crinoline which has been shrunken by being moistened 
and allowed to dry before being employed ; otherwise, dan- 
gerous compression of the part may occur if the bandage- 
has been firmly applied and shrinks after its application. 

The Paraffin-bandage. — Paraffin, which melts at from 
105° to 120° F., is used in the application of this band- 
age. The limb being covered by a flannel roller, a vessel 
containing paraffin is placed in a basin of boiling water. 
As the roller, which may be either of flannel, cheese-cloth, 
or crinoline, is unwound, it is passed through the melted 
paraffin and applied to the part, and the turns are repeated 
until a dressing of sufficient thickness results, when the 
surface may be brushed over with melted paraffin. This 
dressing sets very rapidly, being quite firm in from five to 
ten minutes. 

Moulded Splints. 

Raw-hide or Leather Splints. — In moulding raw- 
hide or leather splints, it is necessary, first, to apply a 
plaster-of- Paris bandage to the part to which the raw- 
hide splint is to be fitted ; and as soon as the plaster 
has set, it is removed, and a solid plaster cast is next 
made by pouring liquid plaster-of-Paris into this mould. 
When this has become dry, a piece of raw-hide, which 
has been soaked for a time in warm water, is moulded 
to the cast and held firmly in contact with it by tacks 
or a bandage until it has become perfectly dry. It is 
then removed, and its surface is covered with several 
coats of shellac, to prevent its absorbing moisture from 
the skin when applied, and changing its shape. Eyelets 
or hooks are fastened to the edges of the splint, through 
which tapes are passed to secure it in place. 

Made in this manner, raw-hide splints fit the part very 
accurately, and constitute a very satisfactory dressing for 
cases of joint-disease, and in the form of leather jackets 
are often employed in the treatment of disease of the spine 
in place of the plaster-of-Paris jacket (Fig. 126). 

In the treatment of high dorsal or cervical caries a 



120 



BANDAGING. 



Fig. 126. 




leather splint in two sections, which 
rests upon the shoulders and sup- 
ports the head, is often used with 
good results (Fig. 127). 

Binders' Board or Pasteboard 
Splints. — This material, which can 
be obtained in sheets of different 
thicknesses, is frequently employed 
for the manufacture of splints. In 
moulding these splints, a portion of 
the board of the requisite size and 

Fig. 127. 




Leather jacket with jury- 
mast. 



Leather splint for cervical caries. 
(Owen.) 



thickness is dipped in boiling water for a short time, and 
when it has become softened it is removed and allowed to 
cool ; a thick layer of cotton-batting is next applied over 
it, and it is then moulded to the part and held firmly in 
place by the turns of a roller-bandage; in a few hours it 
becomes dry and hard. 

This material, from its cheapness and the ease with which 
it is obtained, is frequently employed to mould splints in 
the treatment of fractures. Moulded splints of this kind 
on account of the ease of their application and removal 
are often useful in the temporary treatment of compound 
fractures and excision of joints to fix the ends of the bones. 
In such cases it is often desirable to inspect and dress the 



FIXED DRESSINGS 121 

wounds until healing has occurred, when a fixed dressing 
of plaster-of-Paris may be employed. 

Porous Felt Splints. — This material is also employed 
for the manufacture of splints, and is applied by dipping 
the material in hot water and then moulding it to the part 
and securing it by a bandage; as it dries it becomes hard. 

Hatters'-felt Splints. — Hatters'-felt may also be em- 
ployed for the manufacture of splints or dressings. It is 
softened by dipping it in boiling water or heating it in the 
flame of an alcohol lamp, and when soft and pliable it is 
moulded to the part, and as it cools it again becomes hard. 
These splints are employed for the same purpose as those 
made of plaster-of-Paris, leather, or pasteboard. 

Elastic Cotton Bandage. — The elasticity of this bandage 
is due to the manner in which the bands are woven. Where 
moderate elasticity is required it is a most useful dressing, 
and has the advantage in that it may be washed without 
interferring with its elasticity. It is used for varicose veins 
of the lower extremities and for joints where moderate 
elastic pressure is required. 



PAET II. 

MINOR SURGERY. 



Antiseptic and Aseptic Surgical Dressings. — This 
subject is considered on page 421. 

MATERIALS USED IN SURGICAL DRESSINGS. 

Lint. — This material is employed in surgical dressings, 
and is of two varieties : the domestic lint, which consists 
of pieces of old linen or muslin which have been thoroughly 
washed or boiled and then dried, or the surgical lint, which 
resembles Canton flannel in appearance; the latter is the 
best material, as it has a greater absorbing capacity. 

Lint is used as a material on which unctuous prepara- 
tions are spread in the dressing of wounds, and is em- 
ployed also as a material for saturating with the various 
solutions which are used in wet dressings, such as lead- 
water and laudanum ; the lint, after being saturated w T ith 
the solution, is covered with rubber-tissue or oiled silk when 
applied, to prevent too rapid evaporation of the solution. 
It is also one of the best materials from which to construct 
the compresses employed in the treatment of fractures. 

Paper-lint. — This is made from old rags or wood-pulp, 
has great absorbing power for fluids, and may be used as 
a substitute for surgical lint in the application of wet 
dressings to surfaces when the skin is unbroken. 

Oakum. — This material, made from old tarred rope, 
was formerly much employed in the dressing of wounds, 
before the introduction of the antiseptic method of 
wound treatment. From its elasticity it is found to be 
an excellent material for padding splints or other surgical 
appliances. It is employed also in the form of pads to 
place under patients to relieve portions of the body from 
pressure, or to absorb discharges which soak through the 

123 



124 MINOR SURGERY. 

dressings. A mass of oakum which has been well teased 
out and wrapped in a towel forms an excellent pillow on 
which to support a stump. 

Cotton. — Cotton is now employed in surgical dressings 
principally as a material to pad splints or to relieve 
salient parts of the skeleton from pressure in the applica- 
tion of splints or bandages ; for instance, in the applica- 
tion of the plaster-of- Paris bandage, the bony prominences 
are generally covered with small masses of cotton. It pos- 
sesses but little absorbent power unless used in the form 
of absorbent cotton, and is not much employed in surgical 
dressings except for the purposes mentioned above. 

Absorbent Cotton. — This material is prepared from 
ordinary cotton, which is boiled with a strong alkali to 
remove the oily matter which it contains. When so pre- 
pared, it absorbs liquids freely, and by reason of its great 
absorbing capacity it is employed largely in surgical dress- 
ings. A small mass of sterilized absorbent cotton wrapped 
upon the end of a probe is now generally employed to 
make applications to wounds, and has taken the place of 
the sponge or brush which formerly was employed for this 
purpose. On account of its cheapness, after one applica- 
tion it can be thrown away and a new piece used, and thus 
the danger of carrying infection from one wound to an- 
other by the applicator is abolished. It is largely em- 
ployed in gynecological practice for making applications 
to the female genital organs. 

Wood-wool. — Wood-wool made from wood-pulp, such 
as is employed in the manufacture of paper, is also fur- 
nished in the shape of lint, sponges, and pads, and may be 
used for the same purposes as the ordinary surgical lint. 

Oiled Silk or Muslin. — These materials are employed 
as an external covering for moist dressings to prevent 
rapid evaporation from the dressings ; they form excellent 
materials for this purpose, but as they are quite expensive 
their use is limited. 

Waxed or Paraffin-paper. — This dressing is prepared 
by passing sheets of tissue-paper through melted wax or 
paraffin, and then allowing them to dry. Paper thus treated 
forms an excellent and cheap substitute for oiled silk or 



TAMPON. 125 

muslin, and may be employed for the same purpose for 
which the latter materials are used. 

Rubber-tissue. — This material, which is prepared by 
rubber manufacturers, consists of rubber run out into very 
thin sheets. It has a glazed surface, is very pliable, and 
at the same time strong, forming, therefore, a cheap and 
satisfactory substitute for oiled silk, and is employed for 
the same purposes. A tent made of rubber-tissue may be 
used as a drain for wounds ; it is also used in making the 
cigarette drain. 

Parchment-paper. — This paper is prepared so as to 
render it water-proof; it is employed in surgical dressings 
for the same purposes as oiled silk and rubber- tissue. 

Compresses. — Compresses are prepared by folding pieces 
of lint, muslin, linen, or gauze upon themselves, so as to 
form firm masses of variable size ; oakum or cotton may 
also be used to form compresses. Compresses are em- 
ployed to make pressure over localized portions of the 
body, as in the treatment of fractures, or to make press- 
ure upon vessels for the control of hemorrhage. 

Tampon. — A tampon is a form of compress which is 
employed in cavities to make pressure, to control hemor- 
rhage, or to apply various solutions or powders to the 
surface of the cavity. Tampons used to control hemor- 
rhage are generally made of strips of bichloride, iodo- 
form or sterilized gauze. In applying these, the strips of 
gauze are packed into the cavity, and when the latter is 
full a compress is applied superficially and held in place 
by a bandage. The application of a tampon to the vagina 
is a favorite method of controlling uterine hemorrhage. 

Glycerin Tampon. — This is made by pouring half an 
ounce of glycerin on a piece of cotton or wool, and then 
turning up the ends and securing them by a string, one 
end of which is allowed to remain long enough to hang 
from the vagina, to facilitate its removal ; it is a favorite 
application to the os uteri. The glycerin may be medi- 
cated with any drug that is desired, ichthyol and iodine 
being frequently employed. 

Tent. — This consists of a small portion of lint, oakum, 
muslin, or sterilized or antiseptic gauze rolled into a coni- 
cal shape, which is employed to keep wounds open and to 
facilitate the escape of discharges. 



126 



MINOR SURGERY. 



Sand-bags, or Sand Pillow. — These are muslin bags, 
covered with rubber cloth, of different sizes and shapes, and 
filled with dried sand. They are placed under the skull 
and extremities in operations upon these parts, and in oper- 
ations upon the gall-bladder a sand-bag placed under the 
spine renders that organ and the ducts much more acces- 



Fig. 128. 



Fig. 129. 





Two-tailed retractor. 



Three-tailed retractor. 



sible. A bag from eight to twelve inches square and three 
inches in thickness is one of convenient size. 

Retractors. — Retractors are made by taking a piece of 
muslin four inches wide and twelve to eighteen inches in 
length, and splitting it as far as the centre, thus making a 
huo-tailed retractor (Fig. 128). A three-tailed retractor is 
made in the same way, except that the muslin is slit twice 
instead of once (Fig. 129). Retractors are used to retract 
the soft parts in amputations, to prevent their injury by 



PLASTERS. 127 

the saw in the division of the bones. When one bone is 
sawed a two-tailed retractor is used, and when two bones 
are sawed a three-tailed retractor is employed. 

Plasters. — The varieties of plaster which are most com- 
monly employed in surgical dressings are adhesive or resin 
plaster, isinglass plaster, and rubber adhesive plaster. 

Before using any of these plasters upon parts which are 
covered by hairs, the latter should be removed by shaving, 
otherwise traction upon them, if the plaster be used for 
the purpose of extension, will cause the patient discom- 
fort, and unnecessary pain will also be inflicted at the time 
of its removal. 

Resin Plaster. — This plaster, which is machine-spread, 
is employed frequently in surgical dressings ; the spread 
surface is covered with a layer of tissue-paper, which should 
be removed before it is used ; it is cut into strips of the 
required width and length, and the strips should be cut 
lengthwise from the roll of plaster, as the cloth upon which 
it is spread stretches more transversely than in a longitudi- 
nal direction. When heated and applied to the surface it 
holds firmly ; it is prepared for application by applying the 
unspread side to a vessel containing hot water, or it may 
be passed rapidly through the flame of an alcohol lamp. 

This is the variety of plaster w r hich is generally used in 
making the extension-apparatus for the treatment of fract- 
ures, for strapping the chest in fractures of the ribs and 
sternum, for strapping the pelvis in cases of fractures of 
the pelvic bones, and for strapping the breast, the testicle, 
ulcers, or joints. 

Swans'-down Plaster. — This plaster is much the same as 
resin plaster, but is spread upon a heavier material, and 
is an excellent plaster to use for an extension-apparatus, 
where it is to be worn for a long' time. 

Ichthyol Plaster. — This plaster is prepared by incorpor- 
ating ichthyol and the ordinary rubber plaster, it is much 
less irritating to the skin and possesses the same adhesive 
properties and is used for the same purposes as the resin 
or zinc oxide plasters. 

Rubber Adhesive Plaster. — This plaster is made by 
spreading a preparation of India-rubber on muslin, and 



128 MINOR SURGERY. 

has the advantage over the ordinary resin plaster that it 
adheres without the application of heat. It is employed 
for the same purpose as resin plaster, but when applied con- 
tinuously to the skin it is apt to produce a certain amount of 
irritation, and for this reason when it is to be applied for 
some time, as in the case of an extension -apparatus, it is not 
so comfortable a dressing as that made from resin plaster. 

Zinc Oxide Adhesive Plaster. — This plaster is prepared 
by incorporating with rubber adhesive plaster oxide of 
zinc. It is equally as adhesive as the rubber plaster, and 
possesses the advantage that it is not apt to produce irrita- 
tion of the skin. This plaster has largely supplanted both 
the resin and rubber adhesive plaster in surgical dressings. 

Sterile Z. 0. Plaster. — The ordinary adhesive plaster 
cannot be sterilized after it has been made, but the plaster 
manufacturers now furnish a reliable sterile plaster. It 
may be used to approximate the skin in wounds where 
subcutaneous sutures have been employed, or in any case 
where support of a wound is required or where an aseptic 
dressing is essential. 

Isinglass Plaster. — This plaster is made by spreading a 
solution of isinglass upon silk or muslin, and it has been 
found a most useful dressing in the treatment of superficial 
wounds. It is caused to adhere to the surface by moisten- 
ing it, and when used in the treatment of wounds it should 
be moistened with an antiseptic solution. The best variety 
is spread on muslin, and when properly applied adheres as 
firmly and possesses as much strength as the ordinary resin 
plaster. 

Soap Plaster. — Soap plaster for surgical purposes is 
prepared by spreading emplastrum saponis upon kid or 
chamois skin. It is not employed for the same purposes 
as the resin or rubber plaster, as it has little adhesive 
power, and is used simply to give support to parts or to 
protect salient portions of the skeleton from pressure. It 
is found to be a most useful dressing when applied over 
the sacrum in cases of threatened bedsores, and may be 
applied for the same purpose to other parts of the body 
wdiere pressure-sores are apt to occur. 

In the treatment of sprains of joints, a well-moulded 



STRAPPING 129 

soap-plaster splint secured by a bandage will often be found 
a most efficient dressing, and in the treatment of fractures the 
comfort of the patient is often materially increased by apply- 
ing small pieces of soap plaster over the bony prominences, 
upon which the splints, even when well padded, are apt to 
make an undue amount of pressure. 

STRAPPING. 

This consists in applying pressure to parts by means of 
strips of plaster firmly applied. It is a procedure often em- 
ployed in surgical practice. Resin adhesive plaster was for- 
merly employed, but as it has to be heated before used it 
is usually found more convenient to employ some form of 

Fig. 130. 





Strapping the testicle. 

rubber adhesive plaster, of which Z. O. plaster is the least 
irritating to the wound and is the one most frequently used. 

Strapping the Testicle. — In strapping the testicle, strips of 
resin or Z. O. plaster are usually employed; a dozen or more 
strips \ inch wide and 12 inches in length will be required. 

The scrotum should first be washed and shaved, and the 
surgeon next draws the skin over the affected organ tense by 
passing the thumb and finger around the scrotum at its upper 
portion, making circular constriction; a strip of muslin is 
passed in a circular manner around the skin of the scrotum 
above the organ, and is tightly drawn and secured by passing 
around it a strap of plaster; this isolates the part and prevents 
the other straps from slipping. Straps are now applied in a 
longitudinal direction, the first strap being fastened to the 
9 



130 MINOR SURGERY 

circular strap and carried over the most prominent part of 
the testicle, and then carried back to the circular strap and 
fastened. A number of these straps are applied in an imbri- 
cated manner until the skin is covered (Fig. 130), and the 
dressing is completed by passing transverse straps around 
the testicle from its lowest portion to the circular strap ; care 
should be taken to see that no portion of the skin is left 
uncovered. 

Strapping the testicle is employed with advantage in the 
subacute stage of orchitis or epididymitis. As the swelling of 
the testicle diminishes the straps become loose, and the part 
will require restrapping. It will also be found a useful means 

of applying pressure to the scrotum 
Fig. 131. after the injection treatment of hydro- 

cele. 

Strapping of the Chest. — To strap 
one-half of the chest, strips of resin 
or Z. O. adhesive plaster 2\ inches 
wide, and sufficiently long to extend 
from the spine to the median line of 
the sternum, are required — 18 to 20 
inches in length. The first strap is 
placed upon the spine opposite the 
strapping over the chest. lower portion of the chest; it is then 

carried over the chest, and its other 
extremity is fixed upon the skin in the median line of the 
sternum. Straps are next applied from below upward in the 
same manner, each strap overlapping one-third of the preced- 
ing one, until the axillary fold is reached (Fig. 131) ; a second 
layer of straps may be applied over the first, if additional 
fixation is desired, or a few oblique straps may be employed. 
Adhesive straps applied in this manner very materially 
limit the motion of the chest-wall upon the affected side, and 
are frequently employed in the treatment of fractures and 
dislocations of the ribs, in contusions of the chest, and in 
cases of plastic pleurisy when the motions of the chest-wall 
are extremely painful to the patient. 

Strapping of Ulcers. — This method of treating ulcers in their 
chronic stage is most satisfactory, and may be applied to 




POULTICES 131 

ulcers in any part of the body. Properly applied straps tend 
to approximate the edges of the ulcer and diminish its size, 
and also appear to stimulate the growth of the epithelium 
from its edges. After the application of the straps, a gauze 
dressing or an ointment dressing should be applied, and the 
strapping should be renewed at intervals of a few days. (For 
method of strapping employed in ulcers of the leg, see p. 377). 

Strapping of Joints. — This treatment is frequently employed 
in sprains of the wrist, knee and ankle-joint (see p. 339). 

Strapping will be found a satisfactory dressing in the treat- 
ment of sprains of joints in their acute or chronic state. 

Stripsof Z. 0. adhesive or rubber adhesive plaster l^inchesin 
width are applied around the joint, and are made to extend 
some distance above and below it; a gauze bandage is next 
applied over the straps, and the patient is allowed to use the 
part as soon as he can do so without discomfort. 

Strapping the Back. — After contusions or sprains of the lum- 
bar region of the back the firm application of straps gives 
fixation and support to the parts, and relieves pain. The 
patient should be placed in such a position that the spine is 
moderately extended, and strips of plaster 2\ inches in width 
should be applied, one slightly overlapping the other, from 
the upper part of the sacrum to the lower ribs. The straps 
should be long enough to include the posterior half of the 
trunk, and several layers should be applied. 



POULTICES. 

This form of dressing was formerly much employed in the 
treatment of inflammatory conditions as a means of applying 
heat and moisture to the part at the same time, and although 
the use of poultices is now much restricted since the introduc- 
tion of the antiseptic method of wound treatment, yet I think 
there are still conditions in which their employment is both 
useful and judicious. They are often employed with advan- 
tage in inflammatory affections of the chest and of the abdom- 
inal organs; and in inflammatory affections of the joints and 
of bone, combined with rest, their action is often most satis- 



132 MINOR SURGERY 

factory. They constitute a form of dressing which is condu- 
cive to the comfort of the patient in cases of deep suppuration 
by their relaxing effect upon the tissues, and their previous 
use does not prevent the surgeon from using all aseptic pre- 
cautions in the opening and drainage of these abscesses, and 
the employment of aseptic or antiseptic dressings in their 
subsequent treatment. 

Flaxseed Poultice. — This poultice is prepared by adding first 
a little cold water to ground flaxseed, and then boiling and 
stirring it until the resulting mixture is of the consistency of 
thick mush. A piece of gauze or muslin is next taken which 
is a little larger than the intended poultice, and this is laid 
upon the surface of a table, and with a spatula or knife the 
poultice-mass is spread evenly upon it from J to J inch in 
thickness; a margin of the muslin of 1 or 1 J inches is left, 
which is turned over after the poultice is spread, and serves 
to prevent it from escaping around the edges when applied. 
The surface of the poultice may be thinly spread over with 
a little olive oil, or may be covered with a layer of thin gauze, 
to prevent the mass from adhering to the skin. It is next 
applied to the surface of the skin, and is covered with a piece 
of oiled silk, rubber-tissue, or waxed paper, and held in 
position by a bandage or a binder. 

Soap Poultice. — This is made by saturating a number of 
layers of gauze in a mixture of 1 part of green soap to 6 parts 
of water. It is then applied to the surface and covered with 
oiled muslin or waxed paper. It may be employed as a 
primary dressing for some hours to the feet or other parts of 
the body where the epidermis is thick, before sterilizing these 
parts previous to operation. 

Starch Poultice. — This poultice is prepared by mixing starch 
with cold water until a smooth, creamy fluid results; boiling 
water is then added, and it is heated until it becomes clear 
and attains about the same consistency as the starch used for 
laundry purposes. When sufficiently cool, it is spread upon 
gauze or muslin, applied to the part, and covered with oiled 
silk or waxed paper. This variety of poultice is principally 
useful in the treatment of diseases of the skin, especially those 
of the scalp accompanied by the formation of scabs or crusts, 



POULTICES 133 

to facilitate their removal and to afford a clean surface for the 
application of ointments or wet dressings. 

Antiseptic Poultice. — This is prepared by soaking a pad of 
sterilized gauze in hot bichloride, carbolic or saline solution, 
and wringing it out to remove the excess of fluid. It is next 
applied to the part and covered with oiled silk or rubber- 
tissue, which may be held in place by a bandage. Such a 
dressing will absorb a considerable amount of discharge. If 
used for some time, carbolic, or bichloride solutions may cause 
marked irritation of the skin. 

Hot Fomentations. — Hot fomentations are employed to keep 
up the vitality of parts which have been subjected to injury, 
as seen in severe contusions resulting from railway or machin- 
ery accidents; also to combat inflammatory action. Gauze 
(several layers in thickness) or surgical lint should be soaked 
in sterilized water having a temperature of 120° F.; these are 
wrung out, placed over the part, and covered with waxed 
paper or rubber-tissue; a second pad should be placed in the 
hot water, and applied as soon as the first-applied cloth begins 
to cool, and so by continuously reapplying them the part is 
kept constantly covered by a hot dressing. The use of these 
hot fomentations may in many cases require to be continued 
for hours before the desired result is obtained. Hot com- 
presses, dry or moist, applied in this manner are frequently 
employed in treating inflammatory conditions of the eye, and 
are also of the greatest service in keeping up the vitality of 
parts which have been subjected to severe injury interfering 
with their blood supply. I have seen contused limbs, which 
were cold and seemed doomed to gangrene by reason of dimin- 
ished blood-supply, have their temperature and circulation 
restored by the patient and persistent use of this dressing. 
After the vitality of such a part is restored, it should be cov- 
ered with cotton and a flannel bandage and surrounded by 
hot-water bags or hot-water cans. 

Hot Dry Compresses. — These may be used when it is desir- 
able to avoid moisture. Small gauze pads may be heated in 
an electric oven, or in a closed vessel partly immersed in boil- 
ing water, the pads being changed as they cool and replaced 
by hot ones. 



134 MINOR SURGERY 

Lead Water and Laudanum. — This consists of a mixture of 
liquor plumbi subacetatis, gss; tr. opii, §ss; aquae, §iv. 
The strength of this mixture may be varied according to the 
requirements of the case. Lead water and alcohol may also 
be employed. 

This is used as a local application, being applied on lint 
saturated with the solution. 

It has long been a popular application in the early treat- 
ment of fractures, contusions and sprains and in certain forms 
of dermatitis. It should not be applied to open wounds or 
a broken skin surface. 

Magnesium Sulphate Solution. — A saturated solution of mag- 
nesium sulphate is frequently employed as a local application 
in the treatment of inflammatory affections of the joints, 
cellulitis, epididymitis and orchitis. 

The solution may be applied to the affected part by satura- 
ting a number of layers of lint, or 15 to 20 layers of ordinary 
surgical gauze. The dressing should be changed every half 
hour, or covered with waxed paper or oiled muslin to keep 
it moist. It is usually applied for from twenty-four to thirty- 
six hours. It is a cleanly dressing, and seems to relieve pain 
and swelling, and is frequently employed as a substitute for 
lead water and laudanum. 

Ichthyol. — This substance, combined with lard or lanolin, is 
frequently used in the treatment of inflammatory affections. 
The ointment generally employed consists of ichthyol ammo- 
niat., 3ij; adipis or lanolin, 5 j- This may be rubbed over, 
or spread upon lint and applied to the part. It is used in the 
treatment of sprains, inflamed joints, erysipelas, enlarged 
lymphatic glands, frost-bites, chilblains and burns. 



IRRIGATION. 

This may be accomplished by allowing the irrigating fluid 
to come in contact with the wound or inflamed part — imme- 
diate irrigation; or by allowing the cold or warm fluid to pass 
through rubber tubes which are in contact with or surround 
the part — mediate irrigation. 



IRRIGATION 



135 



Immediate Irrigation. — In employing immediate irrigation 
in the treatment of wounds or inflammatory conditions, a 
funnel-shaped can with a stop-cock at the bottom, or a bucket 
is suspended over the part at a distance of a few inches (Fig. 
132), or a jar with a skein of thread or lamp-wick arranged to 
act as a siphon may be employed (Fig. 133). The can or jar 



Fig. 132. 




Apparatus for continuous irrigation. 

is filled with water, and this is allowed to fall drop by drop 
upon the part to be irrigated, which should be placed upon a 
piece of rubber sheeting so arranged as to allow the water to 
run off into a receptacle, to prevent wetting the patient's bed. 
The water employed may be either cold or warm, in accord- 
ance with the indications in special cases. If it is desired to 



136 



MINOR SURGERY 



make use of antiseptic irrigation, the water is impregnated 
with carbolic acid or bichloride of mercury, a 1 : 5000 to 
1 : 10,000 bichloride solution, or a 1 : 60 carbolic acid or acetate 
of aluminum solution, being frequently employed with good 
results. 

Antiseptic irrigation employed in this manner will be found 
a most useful method of treating lacerated and contused 
wounds of the extremities in which the vitality of the tissues 
is much impaired ; in such cases water at a temperature of 
100° to 110° F. should be preferred to cool water. 

Fig. 133. 




Irrigating apparatus. 



Under the use of warm irrigation it is sometimes surprising 
to see tissues apparently devitalized regain their vitality in a 
short time ; the absence of tension from the non-introduction 
of sutures and firm dressings, and the warmth and moisture 
kept constantly in contact with the wound by this method of 
irrigation, are the important factors in the attainment of this 
favorable result. 

Mediate Irrigation. — In this method of irrigation cold or 
warmth is applied to the surface by means of cold or warm 
water passing through a rubber tube in contact with the part. 
A flexible tube of India-rubber J inch in diameter, with thin 



IRRIGATION 



137 



walls, and 16 to 20 feet in length, is applied to the limb like a 
spiral bandage, or is applied to a coil to the head, breast or 
joints, and held in place by a few turns of a bandage; the end 
of the tube is attached to a reservoir filled with cold or warm 
water above the level of the patient's body, and the water is 
allowed to flow constantly through the tubing and escape into 
a receptacle arranged to receive it (Fig. 134) . Coils of rubber 
tubing adapted to fit different portions of the body, known as 
Leiter's coils, are frequently employed in this method of irri- 
gation. 

Fig. 134. 




Cold coil applied to arm. 



Cold-water Dressings. — These dressings are applied by bring- 
ing the cold water either directly in contact with the part or 
by applying it by means of a rubber bag or bladder. The 
temperature of the water may vary from cool water to that 
of ice-water. 

These dressings are employed in local inflammatory condi- 
tions. A -favorite method for the employment of this dressing 
is by means of cold compresses, which are made of a few layers 
of gauze or surgical lint, dipped in water of the desired tem- 
perature and applied to the part; they are renewed as soon as 



138 MINOR SURGERY 

they become warm. When it is desirable to have the com- 
presses very cold, they may be laid upon a block of ice or in a 
basin with broken ice; to obtain the best results from their 
employment, they should be renewed at very short intervals. 
Ice-bag. — A convenient method of applying cold without 
moisture is by the use of the ice-bag. This is either a rubber 
bag or bladder, which is filled with broken ice and applied to 
the part. In using an ice-bag, it is better to cover the part 
first with a towel or a few layers of lint or gauze, which pre- 
vent the surface from becoming wet by absorbing the moisture 
which condenses upon the surface of the bag or bladder, and 
thus renders the dressing more comfortable to the patient. 
The ice-bag is often employed as an application to the head in 
inflammatory conditions of the brain or membranes; to the 
abdomen in cases of appendicitis or peritonitis, and is used 
also upon the surface of the body to control internal hemor- 
rhage. The continuous application of an ice-bag in some 
cases gives rise to a local congestion and redness of the skin 
at the point of its application, the appearance being that of 
a burn of the first degree, hence the name ice burn. 

COUNTER-IRRITATION. 

Counter-irritants are substances employed to excite exter- 
nal irritation, and the extent of their action varies according 
to the material used and the duration of their application; 
superficial redness or complete destruction of the vitality of 
the parts to which they are applied may result. 

The use of counter-irritants under favorable circumstances 
is found to have a decided effect in modifying morbid pro- 
cesses, and they are widely employed as local revulsants in 
cases of congestion or inflammation, and in cases of collapse 
for their stimulating effect. 

Caution should be exercised in applying counter-irritants 
to patients who are comatose or under the influence of a nar- 
cotic, for here the sensations of a patient cannot be used as a 
guide to their removal, and their too long-continued applica- 
tion when the vitality of the tissues is impaired may result 
in their superficial destruction. 



CO UNTER-IRRITATION 139 

Rubefacients. — These agents, by reason of their irritating 
properties when applied to the skin, produce intense redness 
and congestion. 

Hot Water. — When it is desired to make a prompt impres- 
sion upon the skin, the application of gauze, muslin, or flannel 
cloths, wrung out in hot water and renewed as rapidly as they 
become cool, will soon produce a superficial redness of the 
integument. 

Spirit of Turpentine. — This drug applied to the skin is a 
very active counter-irritant; it may be rubbed upon the sur- 
face until redness results. When used upon patients whose 
skin is very delicate, its action may be modified by mixing it 
with an equal part of olive oil before applying it; this com- 
bination will be found useful as a rubefacient to the tender 
skin of young children. . 

When redness of the skin has resulted from the application, 
the skin should be wiped dry by means of a soft towel or 
absorbent cotton, to remove any turpentine from the surface, 
which by its continued contact may cause vesication. 

Turpentine Stupe. — -This is prepared by sprinkling spirit of 
turpentine over flannel cloths which have been wrung out in 
hot water, or by dipping hot flannel in warm spirit of turpen- 
tine : prepared in either way, the stupe should be squeezed as 
dry as possible to remove the excess of turpentine before being 
applied to the surface of the body. A turpentine stupe may 
cause vesication if allowed to remain for too long a time in 
contact with the skin; its application for from five to ten 
minutes will usually produce the desired effect; it should 
be removed after this time, and it may be reapplied if 
desired. 

If the patient complains of severe burning of the skin after 
the use of turpentine, the painful surface should be smeared 
freely with vaseline or lard, which will relieve the uncomfort- 
able sensation. 

Tincture of Iodine. — This drug is frequently used as a coun- 
ter-irritant in chronic inflammation. It is painted upon the 
part at intervals until irritation of the skin is observed, when 
its use is discontinued for a few days before reapplying the 
application. 



140 MINOR SURGERY 

Chloroform . — A few drops of chloroform applied to the sur- 
face of the body by means of a piece of lint, muslin, or flannel, 
and covered by oiled silk or rubber-tissue, will excite a rapid 
rubefacient effect. 

Mustard. — Ground mustard or mustard flour, prepared 
from either sinapis alba or sinapis nigra, is one of the most 
commonly used substances to produce rubefacient action. It 
is generally employed in the form of the mustard plaster or 
sinapism, which is prepared by mixing equal parts of mustard 
flour with wheat flour or flaxseed meal, and adding to this 
sufficient warm water to make a thick paste; this is spread 
upon a piece of old muslin, and the surface of the paste cov- 
ered with some thin material, such as gauze, to prevent the 
paste from adhering to the skin. In making a mustard plas- 
ter for application to the skin of a. child, 1 part of mustard 
flour should be mixed with 3 parts of wheat flour or flaxseed 
meal. 

A mustard plaster or sinapism may be allowed to remain 
in contact with the skin for a period varying from fifteen to 
thirty minutes, the time being governed by the sensation of 
the patient; if it is allowed to remain longer, it may cause 
vesication, which is to be avoided, as ulcers produced by 
mustard are very painful and extremely slow in healing. 
After removing a sinapism, the irritated surface of the skin 
should be dressed with a piece of muslin or lint spread with 
vaseline, boric acid or oxide of zinc ointment. 

To excite a rapid revulsive action, the mustard foot-bath is 
often employed ; it is prepared by adding 2 or 3 tablespoon- 
fuls of mustard flour to a bucket or foot-tub of water at a 
temperature of 100° F.; in this the patient is allowed to soak 
his feet for a few minutes. 

Mustard Papers.— Charta? sinapis, which can be obtained 
in the shops ready for use, are a convenient means of obtain- 
ing the rubefacient action of mustard. They are dipped in 
warm water, and as they are generally very strong, it is well 
to place a layer of muslin between the surface of the plaster 
and the skin before applying it to the latter. 

Capsicum. — -This is also sometimes employed alone as a 
rubefacient, but it is generally used in combination with 



COUNTER-IRRITATION 141 

spices, forming the well-known spice plaster; this is prepared 
by taking equal parts of ground ginger, cloves, cinnamon and 
allspice, and adding to them one-fourth part of Cayenne 
pepper; these are thoroughly mixed, enclosed in a flannel 
bag, and evenly distributed; a few stitches should be passed 
through the bag at different points, to prevent the powder 
from shifting its position; before applying it, one side of the 
bag should be wet with warm whisky or alcohol. Capsine 
plasters are employed also to obtain the rubefacient effect of 
Cayenne pepper. 

Aqua Ammonia?. — This may also be employed for its rube- 
facient action. A piece of lint saturated with the stronger 
water of ammonia, placed upon the skin and covered with 
waxed paper, and allowed to remain for one or two minutes, 
will produce a marked rubefacient effect. 

Vesicants. — Where it is desirable to make a more permanent 
counter-irritant effect than that produced by rubefacients, 
substances are employed which by their action on the skin 
cause an effusion of serum, or of serum and lymph, beneath 
the cuticle, thus giving rise to vesicles or blisters; they are 
known as vesicants. The substance most commonly em- 
ployed to produce vesication is cantharis, or Spanish fly, and 
the preparation commonly used is the ceratum cantharidis. 

Fly Blister. — This is prepared by spreading ceratum can- 
tharidis upon adhesive plaster, leaving a margin \ inch in 
width uncovered, which will adhere to the skin and hold the 
blister in position. The time required for a fly blister to 
produce vesication is from four to six hours ; it should then 
be removed, and the surface covered with a flaxseed-meal 
poultice or with a warm-water dressing. When the blister or 
vesicle is well developed, it may be punctured at its most 
dependent part to allow the serum to escape, and it should 
be dressed with vaseline or boric ointment. If for any reason 
it is desired to keep up continued irritation after allowing the 
serum to escape, the cuticle should be cut away and the raw 
surface should be dressed with some stimulating material, 
such as the compound resin cerate. 

Cantharidal Collodion. — This may be employed to produce 
vesication; it is applied by painting several layers upon the 



142 MINOR SURGERY 

skin with a brush over the part on which the blister is to be 
produced. It is a convenient preparation to use when the 
patient would disturb the ordinary blister, as in the case of a 
child or an insane patient, or where the surface is so irregular 
that the ordinary blister cannot well be applied. The after- 
treatment of blisters produced by cantharidal collodion is 
similar to that described above. 

Caution should be observed in using blisters upon the ten- 
der skins of children ; if employed, they should be allowed to 
remain in contact with the skin for a short time only. They 
are contraindicated in patients in whom the vitality of the 
tissues is depressed by adynamic diseases, and in aged persons. 

Strangury, which is shown by frequent and painful micturi- 
tion, the urine often containing blood, sometimes occurs from 
the use of cantharidal preparations as blisters. This condi- 
tion should be treated by the use of opium and belladonna by 
suppository, demulcent drinks and warm sitz-baths, and by 
leeches to the perineum if the symptoms are very severe. 

To avoid the development of strangury, small blisters 
should be employed, and they should not be allowed to remain 
too long in contact with the surface ; cantharidal preparations 
should not be employed in cases where renal or vesical irrita- 
tion has existed or is present . Strangury may also be avoided 
by incorporating opium and camphor with cantharidal cerate. 

Aqua Ammonias Fortior and Chloroform. — These drugs may 
be employed to produce rapid vesication, a few drops being 
placed upon the surface of the body and covered by an 
inverted watch glass for a few minutes; or lint saturated 
with aqua ammonia or chloroform may be placed upon the 
skin and covered with waxed paper or oiled silk. Either of 
these agents applied in this manner, and allowed ti remain 
in contact with the skin for fifteen minutes, will produce 
marked vesication. The blisters resulting from these agents 
are painful and they are only to be used where a rapid result 
is desired. 

Seguins Method of Counter-irritation. — This consists in 
stroking the surface of the skin lightly and rapidly with the 
point of a Paquelin cautery; the lines of stroking may be 
made at right angles; the application is practically painless, 



CO UNTER-IRR1 TA TION 



143 



but a very decided counter-irritant effect is produced. It is 
employed with advantage in neuralgic affections of the spine 
and joints, and in cases of neuritis of superficial nerves. 

Actual Cautery. — This method of counter-irritation is ac- 
complished by bringing in contact with the skin some metallic 
substance brought to a high degree of temperature. This 
constitutes one of the most powerful means of counter-irrita- 
tion and revulsion; it is rapid in its action, and is not more 
painful than some of the slower methods. The cauteries gen- 
erally employed are made of iron, and are fixed in handles 
of wood or other non-conducting material, and have their 
extremities fashioned in a variety of shapes (Fig. 135). The 
irons are heated by placing their extremities in an ordinary 

Fig. 135. 




Cautery irons. 



fire, or by holding them in the flame of a spirit lamp until 
they are heated to the desired point, either a white or a dull- 
red heat. They are then applied to the surface of the skin 
at one point, or drawn over it in lines either parallel to or 
crossing one another. The intense burning which follows the 
use of the cautery may be allayed by placing upon the cautery 
marks compresses wrung out in ice-water or saturated with 
equal parts of lime-water and sweet oil. 

Where the ordinary cautery irons are not at hand, a steel 
knitting needle or iron poker heated in the flame of a spirit 
lamp or in a fire may be employed with equally satisfactory 
results. Where the cautery iron is held in contact with the 
surface for some time to make a deep burn, the pain of its 



144 



MINOR SURGERY 



application may be allayed by placing a mixture of salt and 
cracked ice upon the spot to be cauterized, for a few minutes 
immediately before its application. The cautery iron should 
not be placed over the skin covering salient parts of the 
skeleton or over important organs. 

The actual cautery, in addition to its use in producing 
counter-irritation and revulsion, is often employed to con- 
trol hemorrhage and to destroy morbid growths. 

Fig. 136. 




Paquelin's cautery. 



Paquelin's Thermo-cautery. — A very convenient and effi- 
cient means of using the thermo-cautery is the apparatus of 
Paquelin, which utilizes the property of heated platinum 
sponge to become incandescent when exposed to the vapor 
of benzole or rhigolene (Fig. 136). The cautery is prepared 
for use by attaching the gum tube to the receiver containing 
benzole, and heating the platinum knife or button, which 
also is attached to the benzole receiver by a rubber tube, in 
the flame of the alcohol lamp for a few moments, and then 



BLOODLETTING 145 

passing the vapor of benzole through the platinum sponge, 
which is enclosed in the knife or button, by compressing the 
rubber bulb. The point may be brought to a white heat or 
only to a dull-red heat. 

This form of cautery may be employed for the same pur- 
poses as is that previously mentioned; its great advantage 
consists in the ease with which it can be prepared for use. 
The knives heated to a dull-red heat will be found of great 
service in operating upon vascular tumors, where the use of 
an ordinary knife would be accompanied by profuse or even 
dangerous hemorrhage. Wounds made by the actual cau- 
tery are aseptic wounds, and when dusted with an antiseptic 
powder generally heal promptly under the scab without 
suppuration. 

BLOODLETTING. 

This procedure is often resorted to, to obtain both the local 
and the general effects following the withdrawal of blood from 
the circulation. Local depletion is accomplished by means 
of some one of the following procedures : scarification, punctu- 
ration, cupping and leeching; and general depletion is effected 
by means of venesection or by arteriotomy. 

Scarification. — Scarification is performed by making small 
and not too deep incisions into an inflamed or congested part 
with a sharp-pointed bistoury; the incisions should be in 
parallel lines, and should be made to correspond to the long 
axis of the part, and care should be taken in making them to 
avoid wounding superficial veins and nerves. Incisions thus 
made relieve tension by allowing blood and serum to escape 
from the engorged capillaries of the infiltrated tissue of the 
part. Warm fomentations applied over the incisions will 
increase and keep up the flow of blood and serum. Scarifi- 
cation is employed with advantage in inflammatory condi- 
tions of the skin and subcutaneous cellular tissue and in acute 
inflammatory swelling or edema of the mucous membrane, 
for instance, of the conjunctiva, and in acute inflammation of 
the tonsils, tongue and epiglottis it is an especially valuable 
procedure. 

A modification of scarification, known as deep incisions, is 
10 



146 MINOR SURGERY 

practised in urinary infiltration to establish drainage and to 
relieve the tissues of the contained urine, and to prevent 
sloughing; in threatened gangrene and phlegmonous erysip- 
elas the same procedure is adopted to relieve tension by per- 
mitting of the escape of blood and serum, and its employment 
is often followed by most satisfactory results. 

Puncturation. — This procedure consists in making punctures 
into inflamed tissues with the point of a sharp-pointed bis- 
toury, which should not extend deeper than the subcutaneous 
tissue; it is an operation similar in character to that just 
described, its object being to relieve tension and bring about 
depletion. It is employed in cases similar to those in which 
scarification is indicated, and is resorted to in cases of diffuse 
areolar inflammation or erysipelas. 

Cupping. — Cupping is a convenient method of employing 
local depletion by inviting the blood from the deeper parts to 
the surface of the body. Cupping is accomplished by the use 
or dry or wet cups. When the former are used, no blood is 
abstracted, and the derivative action only is obtained; when 
wet cups are employed, there is an actual abstraction of 
blood or local depletion as well as the derivative action. 

Dry Cupping. — Dry cups as ordinarily applied consist of 
small cup-shaped glasses, which have a valve and stop-cock 
at their summit; these are placed upon the skin and an air 
pump is attached, and as the air is exhausted in the cup the 
congested integument is seen to bulge into the cavity of the 
cup. When the exhaustion is complete the stop-cock is 
turned and the air-pump is disconnected, the cup being 
allowed to remain in position for a few minutes, and is then 
removed by turning the stop-cook and allowing air again to 
enter the cup. This procedure is repeated until a sufficient 
number of cups have been applied (Fig. 137). 

In cases of emergency, when the ordinary cupping glasses 
and air pump are not available, a very satisfactory substi- 
tute may be obtained by taking a wineglass and burning in 
it a little roll of paper, or a small piece of lint or paper wet 
with alcohol, and before the flame is extinguished rapidly 
inverting it upon the skin; or the air may be exhausted by 
the introduction, for a moment or two, of the flame of a 



BLOODLETTING 



147 



spirit lamp into the cup. Applied in this manner, cups will 
draw as well as when the more complicated apparatus is used; 
and when they are to be removed it is only necessary to press 
the finger on the skin close to the edge of the cup until air 
enters it, when it will fall off. Although dry cups do not 
remove blood directly, there is often an escape of blood from 
the capillaries into the skin and cellular tissue, as is evidenced 

by the ecchymosis which frequently re- 
mains for some days at the seat of the 
cup marks. 

Wet Cupping. — When the abstraction 
of blood as well as the derivative ac- 
tion is desired, wet cups are resorted to, 



Fig. 138. 



Fig. 137. 






Cupping-glass and air-pump. 



Scarificator. 



and here it is necessary to have a scarificator as well as the 
cups and air pump (Fig. 138). 

Before applying wet cups, the skin should be washed care- 
fully with bichloride or carbolic solution, and the scarificator 
should also be sterilized by boiling. A cup is first applied to 
produce superficial congestion of the skin; this is removed, 
and the scarificator is applied and the skin is cut by spring- 
ing the blades. The cups are immediately reapplied and 
exhausted, and they are kept in place as long as blood con- 
tinues to flow. When the vacuum is exhausted and blood 
ceases to flow they should be removed and emptied, and may 
be reapplied if it is desirable to remove more blood. A sharp- 



148 



MINOR SURGERY 



pointed bistoury which has been sterilized may be employed 
to make a few incisions into the skin instead of the scarifica- 
tor, and improvised cups may be employed if the ordinary 
cupping apparatus cannot be obtained. 

After the removal of wet cups the skin should be washed 
carefully with a bichloride or carbolic solution, and an anti- 
septic dressing should be placed over the wounds and held 
in place by a roller bandage. 

Leeching. — The abstraction of blood by 
Fig. 139. leeches is not employed at the present time. 
Two varieties of leeches were used — the Ameri- 
can leech, which drew about a teaspoonful 
of blood, and the Swedish leech, which drew 
three or four teaspoonfuls. 

The Mechanical Leech. — The mechanical 
leech is an apparatus which has been con- 
structed to take the place of the leech; it 
consists of a scarificator, cup and exhausting 
syringe or air pump (Fig. 139). In using 
this apparatus, after the scarificator has been 
used the piston of the exhausting instrument 
should be drawn out slowly, which secures a 
better flow of blood than if a sudden vacuum 
is created. 

Venesection. — Venesection, as its name im- 
plies, consists in the division of a vein, and 
it is the ordinary operation by which general 
depletion or bleeding is accomplished. Vene- 
section at the bend of the elbow is the oper- 
ation which is now usually resorted to for gen- 
eral bloodletting; the vein selected is the median cephalic, 
which is further from the line of the brachial artery than 
the median basilic vein (Fig. 140). 

To perform venesection the surgeon requires a bistoury or 
lancet — the spring lancet was formerly much used, but it is 
not employed at the present time — several bandages, a small 
antiseptic dressing, and a basin to receive the blood. 

The patient's arm should carefully be cleansed, washed over 
with a bichloride solution or painted with tincture of iodine, 



Mechanical leech 



BLOODLETTING 149 

and a few turns of a roller bandage placed around the middle 
of the arm, being applied tightly enough to obstruct the ven- 
ous circulation and make the veins below become prominent, 
but not tight enough to obstruct the arterial circulation. The 
patient at the same time should be instructed to grasp a stick 
or a roller bandage and work his fingers upon it. The surgeon 
should next assure himself that there is no abnormal artery 
beneath the skin, and having selected the vein, the median 
cephalic by preference, he steadies it with the thumb and 
passes the point of the bistoury or lancet beneath it and cuts 
quickly outward, making a free skin opening. The blood 
usually escapes freely and the amount withdrawn is regulated 
by the condition of the pulse and the appearance of the 

Fig. 140. 




Venesection. 

patient. For this reason it is better to have the patient 
sitting up or semi-reclining when venesection is performed, 
as the surgeon can appreciate better the constitutional effects 
of the loss of blood while the patient is in this position. 

When a sufficient quantity of blood has been removed a 
sterile gauze compress is placed over the wound of the vein 
and the bandage removed from the arm above. The com- 
press is held in position by a figure-of-eight bandage. The 
dressing need not be disturbed for five or six days, at which 
time the wound is usually found to be healed. 

Wounds of the brachial artery have occurred in opening 
the veins at the bend of the elbow, but if care is taken, this 
accident should not take place. 

Venesection may be practised on the external jugular win 



150 MINOR SURGERY 

when, from excess of fat or in the case of children, the veins 
at the bend of the elbow cannot be easily found. The vein 
is rendered prominent by placing the thumb or a pad over 
the vein at the outer edge of the sternocleidomastoid muscle 
just above the clavicle. The vein is next opened over this 
muscle by an incision parallel to its fibers. After a sufficient 
quantity of blood has escaped the wound is washed with an 
antiseptic solution and closed by a compress of antiseptic 
gauze held in position by a bandage carried around the neck. 

The internal saphenous vein is also sometimes selected for 
venesection, and here care should be taken not to wound the 
accompanying nerve which lies directly behind the vein. 

Arteriotomy. — This operation is now scarcely ever per- 
formed; but if done, the vessel generally selected is the 
anterior branch of the temporal artery. The position of the 
vessel is fixed by the finger and thumb, and it is opened by 
a transverse incision with a bistoury. After a sufficient quan- 
tity of blood has escaped the wound is inspected, and if the 
vessel is not completely divided, its division is completed 
and the ends of the vessel should be secured with ligatures, 
and the wound closed with sutures. A gauze compress should 
next be applied and held in position by a firmly applied 
bandage. 

TRANSFUSION OF BLOOD. 

This consists in introducing blood into the circulation of 
a patient who is suffering from anemia. Transfusion of 
blood has been employed for many years, but under the 
older methods subjected the patient to great risk and grad- 
ually fell into disuse until revived by Crile. Improvement 
in the technic of the operation and examination of the blood 
of the donor and recipient to eliminate the danger of hem- 
olysis have been the important factors in the revival of this 
procedure. 

The brilliant results following the use of intravenous saline 
solution, as a means of restoring intracardiac pressure, also 
tended to the disuse of transfusion of blood, but it has been 
shown that the results of the former procedure are much less 



TRANSFUSION OF BLOOD 151 

lasting. The use of saline solution is most efficient in 
emergencies, but does not preclude the employment of trans- 
fusion of blood later, which is much more lasting in its 
effects. 

Transfusion of blood with the modern technic is a com- 
paratively safe procedure. Bernheim records 800 transfu- 
sions with hemoglobinuria in 15 cases with 11 deaths and 4 
recoveries. The causes of death in this operation are hemol- 
ysis, embolism and acute dilatation of the heart. 

Hemolysis. — The destruction of the red blood corpuscles is 
a pathological process which always occurs when the blood of 
different species are mixed. Bloods of the same group neither 
hemolize or agglutinate each other. Hemolysis never occurs 
when agglutination is absent. In the case of two human 
beings not of the same type the serum of one may destroy the 
blood corpuscles of another, liberating in the circulation the 
hemoglobin contained in them, the result being hemoglobin- 
uria, as the liberated hemoglobin is secreted by the kidneys. 

Individuals may be classified in one of four groups, accord- 
ing to the agglutinative action of their serum and corpuscles 
with the sera and corpuscles of individuals of the other three 
groups. To determine the group of an individual it is neces- 
sary to test his corpuscles against known sera of Group II and 
III. Lee's classification of blood groups is often employed 
and is shown in the following table : 

CELLS. SERUM. 

I. II. III. IV. 

I o + + + 

II . . + + 

III + + 

IV 

+ = agglutination. = no agglutination. 

In testing the blood of an individual place a drop of Group 
II serum on left side of a glass slide, and a drop of Group III 
serum on the right half of the slide. Puncture the finger of 
the individual to be tested, and transfer to the sera about 
half a drop of blood on end of a glass rod, mixing the blood 
intimately with the serum. Care should be taken to transfer 



152 MINOR SURGERY 

the blood before coagulation has commenced, and to avoid 
mixing the two sera. Shaking the slide hastens the appear- 
ance of an agglutination. Red cells make a uniform suspen- 
sion in the citrated serum. If there is no agglutination and 
the test is negative this suspension persists. If the test is 
positive and agglutination takes place it usually appears in 
less than a minute in the form of masses of agglutinated cells 
which can be recognized by the naked eye. 

As a rule, the donor should be selected from the same group 
as the one to which the recipient belongs. It is not difficult 
when the patient is a member of Group II or IV (common 
group), but may be difficult when the patient is a member of 
Group I or III. For the latter a Group IV donor is more 
suitable. Where a donor of the same group is not available, 
Group IV donors may be used for any of the four groups. 
Group IV corpuscles are not agglutinated by any serum, and 
the agglutinative reaction of Group IV serum upon the 
corpuscles of any of the three other groups is unimportant 
because the serum is promptly diluted by the serum of the 
recipient. Group IV donors are termed universal donors. 
The serum of Group I does not agglutinate the cells of 
any group, and may receive blood from any of the four 
groups. Members of Group I are termed universal recipients. 

The Donor. — The selection of the donor is most important. 
He should be a young person in good health; the very young 
and old should be eliminated. He should have a negative 
Wassermann test, and should also be examined for tubercu- 
losis and malaria. Blood relatives are apt to furnish blood of 
the same group and are good donors if of suitable age. Pro- 
fessional donors are often employed. Many hospitals have 
lists of these for use in emergencies; they should be retested 
at short intervals. The amount of blood taken from a donor 
should not be more than 750 cc to 1000 cc. If more blood is 
required two donors should be employed. 

During removal of blood from the donor he should be care- 
fully watched. If pallor develops the blood-pressure falls 
suddenly, and the pulse becomes weak, the removal of blood 
should be promptly stopped. 

Transfusion of blood is the most effective treatment for 



TRANSFUSION OF BLOOD 153 

acute anemia resulting from profuse hemorrhage. The sud- 
den loss of a large amount of blood is much more serious than 
the gradual loss of the same amount of blood. It is now 
frequently employed as a preoperative procedure in patients 
who are anemic and exhausted from infection, and show a low 
blood-pressure combined with a low blood count, hemoglobin 
50 or less and red corpuscles 2,000,000 or less. Such cases 
without transfusion are often poor operative risks, but after 
transfusion become favorable risks and show an improved 
blood picture. It is sometimes employed during the opera- 
tion or immediately afterward, with the best results. It has 
also been employed in constitutional diseases which are char- 
acterized by a disordered state of the blood, primary perni- 
cious anemia, hemophilia, leukemia and in jaundice cases 
requiring operation, but showing very slow coagulation; in 
postpartum hemorrhage, or that occurring in typhoid fever, 
and in shock complicated by acute anemia following hemor- 
rhage. In poisoning by illuminating gas this procedure is 
especially indicated. The patient may be given 500 cc to 
1000 cc. When larger amounts are given the blood from two 
donors would be required. It should be noted that children 
require much less blood than adults to attain the same result. 

The symptoms which point to the need for transfusion of 
blood are coldness and pallor of the skin, rapid weak pulse, 
air hunger, thirst and low blood-pressure. When the latter 
is as low as SO the condition is urgent. After transfusion the 
pulse, which has been 140 to 150, should fall to 100, and the 
blood-pressure should rise from a point below 80 to 110 to 112. 

Transfusion may be accomplished by the direct method, in 
which the blood is conveyed directly and without exposure to 
the air from the bloodvessels of one person to those of another. 
In the indirect method the blood is first taken from vessels of 
one person, and is injected or allowed to flow by gravity into 
the vessels of another. Crile, Bernheim, Unger, Hartwell, 
Brewer and Fauntleroy have devised methods of direct trans- 
fusion which have been extensively employed. The indirect 
methods of transfusion used by Lewisohn, Kimpton Brown 
and Vincent are widely used at the present time. Transfu- 
sion from vein to vein does not furnish sufficient current unless 



154 MINOR SURGERY 

an artificial pump is employed. In all methods of transfusion 
the entrance of air with the blood should be avoided. Crile 
devised a method of arterio-venous anastomosis which brings 
the endothelium of the artery of the donor in contact with the 
endothelium of the vein of the recipient, so that clotting does 
not take place. The donor and recipient are laid side by side 
on two tables, head to foot. 

Crile's Method. — Crile exposes the radial artery of the donor 
and a superficial vein of the recipient under infiltration anes- 
thesia. A Crile clamp is applied to the proximal end of the 
artery and the distal end is ligated and the artery divided, the 
vein of the recipient having been exposed the distal part is 
ligated, and the proximal closed with a Crile clamp. The 
vein is then pushed through a small silver cannula and the 
freed end turned back like a cuff and secured by a ligature. 
The artery is then dilated and slipped over the vein and 
snugly tied with a fine ligature. This completes the anas- 
tomosis and upon removing the clamps the blood passes from 
the artery of the donor to the vein of the recipient. 

Bernheim has devised for the direct transfusion of blood 
a two-piece cannula, one section of which is introduced into 
the artery of the donor, the other section is placed in the 
vein of the recipient. The tubes are filled with liquid vaseline 
before the union is effected. When this is done and the 
clamps removed the anastomosis is completed. 

Fig. 141. 



Brewer's tube. 



Brewer's Method. — Brewer devised and used a glass tube 2J 
inches long, small at one end for insertion into the artery, 
larger at the other for application to the vein. The tube 
before being used is coated with paraffine by being dipped in 
melted paraffine, or in a solution of paraffine in benzine (Fig. 
141). Brewer connected the radial artery of the donor with 
the median basilic or other available vein of the recipient. 



TRANSFUSION OF BLOOD 155 

Hartwell's Method. — This consists in making a direct con- 
nection between an artery and vein without the intervention 
of a tube. The artery and vein are exposed and clamped. 
The adventitia is removed from each, except that a small 
cuff from the cut end is left curled up on the outside of the 
artery, about 1J inches from the proximal cut end. Three 
fine silk sutures are passed at equally distant points through 
the edge of the circumference of the vein. The end of the 
artery is lubricated with sterilized vaseline, and the mouth 
of the vein is held open by the three sutures, and the artery 
is passed directly into it for the distance of 1 inch. One of 
the sutures in the vein is passed through the rolled-up adven- 
titia of the artery, and the excess caliber of the vein is closed 
around the artery with a clamp or sutures. The occluding 
clamps are removed and the blood is allowed to flow. 

Lewisohn's Sodium Citrate Method. — Lewisohn found that by 
mixing sodium citrate in 0.2 per cent solution with blood 
the mixture could not coagulate and will remain fluid for two 
days. The advantage of citrate mixture is that coagulation 
need not be feared in the apparatus. It also can be carried 
from the donor to the recipient at a distant point. The tech- 
nic of the citrate method is simple. The arm of the donor in 
the region of the elbow is painted with tincture of iodine and 
a tourniquet applied below the shoulder. The median ceph- 
alic vein is punctured with a large sterilized hollow needle, or 
a trocar and cannula. The blood should flow into a warmed 
graduated glass vessel containing 2 per cent, solution of 
sodium citrate. If an infusion of 500 cc is to be given, 50 cc 
of sodium citrate is placed in the jar and 450 cc of blood is 
added, and the mixture is constantly stirred with a glass rod. 
The recipient's arm is sterilized, and a vein at the elbow, 
perferably the median cephalic, is exposed and punctured with 
a hollow needle attached to a tube and glass funnel, which is 
kept filled with normal salt solution. As soon as the salt solu- 
tion is passing freely from the funnel into the vein blood is 
poured into the funnel, care being taken that the latter does 
not become empty. As soon as the desired amount of blood 
has been given the needle is removed and the wound is closed 
with sutures and a gauze compress and bandage applied. 



156 MINOR SURGERY 

Some surgeons prefer to use a cannula instead of the hollow 
needle to introduce the blood into the vein of the recipient. 
In this case the vein being exposed, two catgut literatures are 
passed around the vein about \ inch apart, the distal ligature 
is tied and the vein is picked up with forceps between the 
ligatures, and a small opening made into which the cannula 
is inserted and secured by tying the proximal ligature. When 
a sufficient quantity of blood has been introduced salt solution 
is poured into the funnel and as the cannula is withdrawn the 
proximal ligature is tied. 

Slight reaction sometimes follows the use of citrated blood, 
but I have personally never seen any serious symptoms follow 
its use. 

Kimpton Brown's Method. — In this procedure a graduated 
glass tube, holding 100 to 250 cc, has its lowest portion 
drawn to a hollow point and is ground to fit a cannula. This 
tube has its inner surface coated with paraffine to prevent 
clotting of the blood. A vein at the elbow is exposed. A 
cannula may be introduced in the vein and attached to the 
glass tube, or the end of the tube may be inserted in the vein 
and secured by a catgut ligature. When the requisite 
amount of blood has been obtained the tube is withdrawn 
and the wound dressed. As rapidly as possible the cannula 
is now inserted into the vein of the recipient. Air pressure 
is now applied to the contents of the tube by means of a 
rubber bulb attached to an outlet at the top of the tube and 
in this way the blood is forced into the vein of the recipient. 

The various methods of direct and indirect transfusion 
described above have all been used with satisfactory results. 
The results of the direct method in hands of experts cannot be 
excelled, but for ease of performance, general adaptibility and 
satisfactory results, the citrated blood method which was the 
method of transfusion employed by the Medical Department 
of the United States in the late war is to be recommended. 
The objection to this method, that the sodium citrate acts 
upon the blood corpuscles, causing a diminution of the 
coagulability of the recipient's blood, is negligible, as it has 
been shown that it is actually increased. Febrile reactions, 
however, are more common than with the direct methods. 



INTRAVENOUS INFUSION OF SALINE SOLUTION 157 

Arterial Transfusion. — This procedure has been advocated 
by Heuter, who preferred this method of transfusion as tend- 
ing to send the blood gradually to the heart and thus 
prevent sudden disturbance of the circulation. If the proxi- 
mal end of the artery of the donor is anastomosed with the 
proximal end of the artery of the recipient, there is practically 
no risk of excessive blood transference, as the two pressures 
will tend to balance at some point lower than the normal. 
The technic of the operation is similar to that of arterial 
anastomosis. 

Autotransfusion.— This procedure is recommended in cases 
of excessive hemorrhage to support a moribund patient until 
other means of resuscitation can be adopted. It consists in 
the application of rubber or muslin bandages to the extremi- 
ties for the purpose of forcing the blood toward the vascular 
and nervous centers. 

INTRAVENOUS INFUSION OF SALINE SOLUTION. 

It has been proved by experiments and by clinical experi- 
ence that saline solution is most efficacious in supplying 
volume to and restoring a rapidly failing circulation, and as 
it can be obtained with much more ease than blood, its use 
for a time largely superseded the latter. With the perfected 
technic of direct and indirect transfusion of blood, recently 
introduced by Carrell and Crile and others, transfusion of 
blood is much more frequently resorted to in the treatment 
of severe hemorrhage. 

It is now known that the grave results following severe 
hemorrhage are due not only to the loss of corpuscular 
elements, but to the mechanical disproportion between the 
area of the vascular system and its content. Saline solution 
introduced into the veins in sufficient quantity increases the 
arterial pressure and restores the activity of the circulation. 

It has been shown by experiments that plain distilled water 
is destructive to the red corpuscles, but that when a certain 
amount of sodium chloride is added this result does not occur. 

Normal saline solution consists of 6 to 9 parts of sterilized 
sodium chloride to 100 parts of distilled water. For practical 



158 



MINOR SURGERY 



purposes it may be prepared by adding a heaping teaspoonful 
of table salt to 1 quart of distilled water. 

Various modifications of normal salt solution have been 
proposed and employed with good results. Of these, Locke's 
is said to be one of the most satisfactory. It consists of dis- 
tilled water, 1 liter; sodium chloride, 9 to 10 gm.; calcium 
chloride, 0.2 gm.; potassium chloride, 0.1 to 0.2 gm.; sodium 
bicarbonate, 0.1 to 0.2 gm.; glucose, 1 gm. 

A vein of the patient at the elbow, should be exposed, and 
should have placed under it about J inch apart two catgut 
ligatures; the distal ligature is then tied and an opening is 



Fig. 142. 




Vein exposed; introduction of cannula. 

made into the vein between the ligatures (Fig. 142) ; a cannula 
is next inserted into the opening in the vein, and is secured in 
position by tying the proximal ligature. The solution should 
be used at a temperature of 105° to 110° F. The cannula is 
first filled with the saline solution, and is then connected 
with a funnel or graduated glass jar by means of a rubber 
tube (Fig. 144), which is filled with saline solution to displace 
the air, and upon raising the funnel above the part the solu- 
tion enters the vein; care should be taken to see that the 
funnel is kept well supplied with the solution until a sufficient 



INTRAVENOUS INFUSION OF SALINE SOLUTION 159 



quantity has been introduced. The quantity introduced into 
the circulation must be regulated by its effects. In acute 
hemorrhagic anemia, 1 or 2 
pints will often restore the Fig. 143. 

radial pulse; larger quan- 
tities may be used. The 
larger the quantity of solu- 
tion required to restore 
the pulse the graver the 
prognosis. In grave cases 
the addition of adrenalin 
chloride solution, 1 to 1000 
to the saline solution, may 
be used with advantage. 
Crile recommends its use 
in the following manner: 
When the fluid begins to 
flow into the vessel, thrust 
the needle of a hypodermic 

syringe filled with the adrenalin chloride solution through 
the rubber tube near the cannula, and during one minute 




Opening the vein. (Ashhurst.) 



Fig. 144. 




Funnel and tube for intravenous infusion. 



inject 10 to 15 mm. The fluid should be slowly and gradually 
introduced; the pulse should be carefully watched during 



160 MINOR SURGERY 

its introduction. Ten minutes should usually be employed 
for the introduction of 1 pint of the solution. 

When a sufficient quantity of the solution has been intro- 
duced, as shown by improvement in the pulse, the cannula 
is withdrawn, the proximal ligature is tied, the wound is 
closed by sutures and a dressing is applied. 

The best results of intravenous infusion has been obtained 
in cases of acute anemia from severe hemorrhage, in shock, 
in anemia, uremia, postoperative suppression of urine and 
occasionally in sepsis. 

Saline solution may also be introduced into a vein by 
means of a syringe when the apparatus described cannot be 
obtained. 

Infusion of Saline Solution into Arteries. — Saline solution may 
be gradually introduced into the circulation through an 
artery. 

The radial artery is exposed and surrounded by these liga- 
tures a short distance apart, the ligature nearest the heart is 
first tied, and next the distal ligature is tightened to cut off 
the anastomotic blood supply; the artery is then partly 
divided and the cannula is inserted pointing toward the 
periphery and fastened by the remaining ligature; the second 
ligature is loosened and the fluid is injected. 

When a sufficient quantity of fluid has been introduced the 
distal ligature is firmly tied, the cannula removed, the division 
of the artery completed, and the w T ound is closed by sutures 
and a dressing applied. 

Infusion of Saline Solution — Hypodermoclysis. — The intro- 
duction of saline solution into the cellular tissue has been 
followed by results equally as satisfactory as those obtained 
by intravenous injection, and this procedure is now very 
frequently employed. 

The saline solution is conveyed into the cellular tissue 
through a large hypodermic needle, which should be sterilized 
by boiling, and is then introduced into the connective tissue, 
being previously connected by a rubber tube with a reservoir 
containing warm sterilized salt solution. The usual situa- 
tions for the introduction of the solution are the external por- 
tions of the thighs and the anterior and lateral portions of the 



INTRAVENOUS INFUSION OF SALINE SOLUTION 161 

abdominal and thoracic walls. As much as two or three pints 
of the solution are often introduced in this manner with good 
results. Infusion of saline solution may be used with most 
satisfactory results in cases who have suffered from profuse 
hemorrhage, and has also proved of great service in cases of 
shock, and has a distinct value in the treatment of septicemia 
and uremia. 

Enteroclysis. — This procedure is employed to supplement 
hypodermoclysis and intravenous saline infusion. It consists 
in introducing into the rectum warm saline solution by means 
of a tube with a nozzle which is attached to a vessel containing 
the solution. 

Fig. 145. 




Fowler's position with enteroclysis. 



Hoi 



The solution is usually introduced in quantities from 
pint every three or four hours, or it may be allowed to perco- 
late slowly into the rectum over long periods of time, as in the 
Murphy method in the treatment of peritonitis. Many 
patients will not retain large quantities of the solution thrown 
into the rectum at once. In such cases, 4 to 6 ounces of the 
solution may be given every two or three hours with good 
results. This method is most satisfactory in children who 
do not retain well large amounts of saline solution. 

Murphy, in cases of diffused peritonitis, recommends that 
the patient be placed in the Fowler position to drain fluids 
into the pelvis — that is, a sitting or semi-sitting posture, and 
that he be given saline solution by the rectum continuously, 
the vessel containing the fluid being raised slightly above the 
U 



162 MINOR SURGERY 

body and the tube so arranged that the fluid passes slowly into 
the rectum, the object being to have only so much fluid enter 
the rectum as will be absorbed (Fig. 145) . The temperature 
of the solution should be about 100° F. This method, with 
abstinence from food, is also most useful as a preoperative 
treatment in patients suffering from peritonitis, as favoring 
localization of inflammation and elimination of toxins by 
the kidneys. 

ASPHYXIA OR APNEA. 

These terms are used to describe a condition in which 
there is non-oxygenation or incomplete oxygenation of the 
blood. In asphyxia death is not immediate, the heart con- 
tinuing to beat for sometime after respiration has ceased, and 
resuscitation is often possible. Asphyxia may result from 
foreign bodies in the air-passages, heavy bodies pressing on 
the chest or air passages, acute traumatic pneumothorax, by 
a clot in the pulmonary artery shutting off the blood supply 
of the lungs, drowning, throttling and irrespirable or irritant 
gases. The prominent symptoms of asphyxia are lividity, 
labored respiratory efforts, turgescence of the veins, convul- 
sions and unconsciousness. Blood may escape from the nose, 
rectum and other mucous membranes, the pulse becomes 
weaker and the heart finally stops beating. 

Sudden asphyxia is usually due to the presence of foreign 
bodies in the air passages or to wounds; gradual asphyxia is 
due to some intrathoracic lesion. The treatment of asphyxia 
consists in opening and examining the mouth for foreign 
bodies, pulling the tongue forward and dashing hot or cold 
water on the face and chest to excite respiratory movements. 
If there is cardiac dilatation bleeding is indicated; stimula- 
tion of the phrenic nerve by electricity may do good, and if 
the patient is breathing oxygen may be of service. Tracheal 
or laryngeal obstruction demand tracheotomy or intubation. 
In threatened death from asphyxiation artificial respiration 
is a most valuable procedure. 

Gas Poisoning. — Inhalation of illuminating gas, either acci- 
dental or with suicidal intent, is quite common at the present 
time. Gas produced from coal by the old process contains 



ASPHYXIA OR APNEA 163 

about 7 per cent carbon monoxide, while that by the new pro- 
cess, known as water gas, has certain hydrocarbons added in 
the manufacture, and contains almost 38 per cent carbon 
monoxide . The latter is much more poisonous than the former . 
Air containing 0.05 per cent of carbon monoxide has a marked 
affinity for hemoglobin and destroys the oxygen-carrying 
power of the red blood cells. 

The symptoms of gas poisoning are vertigo, headache, dizzi- 
ness, weakness, throbbing in the head and great vessels of 
the neck; the pulse may at first be slow, but later becomes 
weak and rapid; respiration rapid and stertorous, or may be 
of the Cheyne-Stokes type. The temperature varies from 
99° to 103° F. The tongue is red and swollen and cherry-red 
spots may be observed upon the surface of the body. Cyan- 
osis is marked and coma may develop rapidly. Pulmonary 
complications (bronchopneumonia) and nervous sequelae may 
develop later if the patient survives. 

T realm ent. — Remove the patient from gas-containing atmos- 
phere. Practice artificial respiration. Administer oxygen 
to displace the carbon monoxide from the blood. Give sodium 
phosphate or Seidlitz powder by the mouth, also spts. 
ammonii aromat., strychnine, digitalis and camphor by the 
mouth, as indicated. If the patient is asphyxiated or coma- 
tose make artificial respiration with pulmotor which at the 
same time furnishes oxygen . Bleed and transfuse with normal 
blood. 

Smoke Asphyxia. — DaCosta has called attention to the fre- 
quency, dangers and treatment of this variety of asphyxia. 
Smoke asphyxia is most commonly met with in firemen. 
The combustion of different substances produces different 
varieties of smoke, some of which are simply irrespirable 
while others are highly poisonous. Heat of the smoke ren- 
ders it more irrespirable. Smoke from lumber, varnish, 
paper, rags, wet hay is very irrespirable ; while that from pitch, 
tar and oil is much less pungent. Smoke impregnated with 
ammonia, sulphur dioxide and chlorine is an active irritant. 
Smoke containing nitric acid is highly irritant and is likely 
to cause edema of the glottis or lungs. 

Three stages of smoke asphyxia are recognized : (1) Respi- 
ration is affected, but the patient is conscious; (2) conscious- 



164 MINOR SURGERY 

ness is lost, but respiration continues; (3) respiration has 
been arrested. 

Treatment. — The patient should be promptly removed from 
the smoky atmosphere; all constricting clothing removed. 
If the patient attempts to vomit this should be encouraged 
by giving effervescent drinks, as vomiting removes the mucus 
and gases from the stomach and lungs. If respiration has 
been suspended the lips are cyanotic, skin cold and clammy, 
the pupils are fixed and dilated, pulse weak and fluttering 
and there is bleeding from the nose and mouth, and sometimes 
involuntary passage of urine and feces. The mouth should 
be cleared of mucus or blood and artificial respiration should 
be started or the pulmotor or the lung motor employed, oxy- 
gen being given. If edema of glottis is present tracheotomy 
should be performed and oxygen administered through the 
tracheal tube. 

ARTIFICIAL RESPIRATION. 

This procedure is resorted to in cases of threatened death 
from apnea consequent upon drowning, profound anesthetiza- 
tion, electric shock or the inhalation of irrespirable gases, or 
when from any cause there is interference with the function of 
breathing. Before resorting to artificial respiration care 
should be taken to see that nothing is present in the mouth 
or air-passages which will obstruct the entrance of air into the 
lungs, such as mucus, foreign bodies or liquids, and also that 
all tight clothing interfering with the free expansion of the 
chest walls is removed from the chest. 

In cases where the apnea is due to the presence of a foreign 
body in the larynx or trachea it is evident that no efforts 
at respiration can be successful until the air passages are freed 
from the occluding body; and if it cannot be removed through 
the mouth, tracheotomy should be performed before artificial 
respiration is attempted ; the tracheal wound should be held 
open by retractors, which in a case of emergency can be made 
from bent hairpins, or by a dressing forceps or a tracheotomy 
tube, if one be at hand. 

When artificial respiration is resorted to the operator should 
persevere with it for some time, even when no apparent spon- 



ARTIFICIAL RESPIRATION 165 

taneous respiratory movements are excited ; for resuscitation 
has been accomplished in seemingly hopeless cases by patient 
perseverance with the manipulations. When the first natural 
respiratory movement is detected the operator should not 
cease making artificial respiration, but should continue these 
movements in such a way as to coincide with the spontaneous 
inspiratory and expiratory movements until the breathing has 
assumed its regular character. 

The temperature of the body should also be restored by 
friction to the surface by the hands or by rough towels and 
hot-water bottles and warm coverings should be applied for 
the same object. 

Direct Method of Artificial Respiration (Howard's). — This 
method of artificial respiration is at the present time con- 
sidered the most efficacious, and is the one adopted by the 
United States Life-saving Service; and although the rules 
given are for the resuscitation of cases of apparent drowning, 
the same procedures may be adopted in cases of apnea arising 
from other causes. 

The rules laid down by Dr. Howard are as follows : 

Rule I. — " To expel water from the stomach and lungs strip 
the patient to the waist, and if the jaws are clenched separate 
them and keep them apart by placing between the teeth a 
cork or a small piece of wood. Place the patient face down- 
ward, the pit of the stomach being raised above the level of 
the mouth by a roll of clothing placed beneath it (Fig. 146) . 
Throw your weight forcibly two or three times upon the 
patient's back over the roll of clothing so as to press all fluids 
in the stomach out of the mouth. 

The first rule applies only to cases of drowning, and in using 
Howard's method in apnea from other causes it is omitted. 

Rule II. — "To perform artificial respiration quickly turn 
the patient upon his back, placing the roll of clothing beneath 
it so as to make the breast bone the highest point of the body. 
Kneel beside or astride of the patient's hips. Grasp the 
front part of the chest on either side of the pit of the stomach, 
resting the fingers along the spaces between the short ribs. 
Brace your elbows against your sides, and steadily grasping 
and pressing forward and upward throw your whole weight 



166 



MINOR SURGERY 



upon the chest, gradually increasing the pressure while you 
count one — two — three. Then suddenly let go with a final 



Fig. 146. 




First manipulation in Howard's method. 



push which springs you back to your first position (Fig. 147) . 
Rest erect upon your knees while you count one — two; then 



Fig. 147. 




Direct method of artificial respiration. 



make pressure as before, repeating the entire motions at first 
about 4 or 5 times a minute, gradually increasing them to 



ARTIFICIAL RESPIRATION 



167 



about 10 or 12 times. Use the same regularity as in blowing 
bellows and as seen in the natural breathing which you are 
imitating. If another person is present, let him with one 
hand, by means of a dry piece of linen, hold the tip of the 
tongue out of one corner of the mouth, and with the other 
hand grasp both wrists and pin them to the ground above 
the patient's head." This method may be employed in cases 
of still-birth or in young children, the operator holding the 
body of the child in his left hand and compressing it with the 
right hand. 

Fig. 148. 




Silvester's method — inspiration. 

Silvester's Method of Artificial Respiration. — In employing 
this method of artificial respiration the patient should be 
placed on his back upon a firm flat surface; a cushion of 
clothing is placed under the shoulders and the head should be 
dropped lower than the body by tilting the surface on which 
he is laid. The mouth being cleared of mucus or foreign 
substances, the tongue is drawn forward and secured to the 
chin by a piece of tape tied around it and the lower jaw, or 
may be pulled out of the mouth and held by an assistant. 
The operator, standing at the patient's head, grasps the arms 
at the elbows and carries them first outward and then upward 



168 



MINOR SURGERY 



until the hands are brought together above the head; this 
represents inspiration (Fig. 148) ; they should be kept in this 
position for two seconds, after which time they are brought 
slowly back to the sides of the thorax and pressed against it 
for two seconds; this represents expiration (Fig. 149). These 
movements are repeated 15 times in one minute until the 
breathing is restored or it is evident that the case is a hope- 
less one. 

Fig. 149. 




Silvester's method — expiration. 



Laborde's Method of Artificial Respiration. — Laborde has 
shown that systematic and rhythmic traction upon the tongue 
is a powerful means of restoring the respiratory reflex, and 
consequently the function of respiration. The procedure is 
accomplished as follows: The body of the tongue is seized 
between the thumb and fingers, and traction is made upon it 
with alternate relaxation, 15 or 20 times a minute, imitating 
the function of respiration, taking care to draw well on the 
tongue. When a certain amount of resistance is felt it is a 
sign that the respiratory function is being restored. Noisy 
respiration first occurs, termed by Laborde hoquet mspirateur 
(inspiratory hiccough) . Tongue forceps or dressing or hemo- 
static forceps may be used in place of the fingers to grasp the 



ARTIFICIAL RESPIRATION 169 

tongue. It is important to persist in the manipulations for 
a half to one hour, unless the case is absolutely hopeless. 
This procedure, which cannot be employed with advantage 
when there is fixation of the tongue from inflammation or 
malignant disease, has been employed with success in cases 
of drowning, toxic asphyxia, asphyxia during anesthesia and 
arrest of respiration from electric shock. 

Schafer's or Prone Method. — In this method of artificial respi- 
ration the patient is placed upon his stomach with the face 
turned to one side, the arms are brought above the head and 
a roll of clothing is placed under the chest. The operator 
kneels astride of the patient and grips the thorax, the fingers 
being parallel to the ribs, the elbows are firmly braced against 
the chest, and press firmly upward and inward, throwing the 
whole weight against the chest. Relieve pressure after two or 
three seconds and count one — two and again make pressure as 
before; repeat these manipulations about 15 times in a minute. 
This position in this method causes the tongue to fall forward 
without being held, and also facilitates the escape of fluids 
from the air passages. 

Pulmotor. — By the use of this apparatus the administration 
of oxygen and artificial respiration are accomplished at the 
same time by means of oxygen which is under pressure. The 
apparatus is contained in a narrow wooden case and weighs 
less than 50 pounds — so that it is quite portable. Hospital 
ambulances, receiving wards and operating rooms are usually 
equipped with this apparatus. The mask is fitted to the 
face and the oxygen is turned on, and by an arrangement of 
valves the lungs are filled with the gas by pressure and 
emptied by suction. After respiration has been established, 
the valve is changed and oxygen is simply given by inhalation. 

It has been shown that the air furnished by the pulmotor 
does not contain over 30 per cent of oxygen. The pulmotor 
is especially valuable in cases of asphyxiation from illumina- 
ting gases, or other poisonous gases, and in cases of drowning. 

Lung Motor. — This apparatus, which is worked by hand and 
can be adjusted with great rapidity, not only furnishes air to 
the lungs but also causes the thorax to exert the proper suc- 
tion upon the great vessels and the heart. Before using the 



170 MINOR SURGERY 

instrument a rubber tube is passed into the esophagus and 
distended with air by means of an attached hand bulb; this 
prevents the air from entering the stomach. Air or air mixed 
with oxygen may be introduced. The mouth is next cleared 
of saliva or mucus and the mask is secured in place and the 
air pumps are started — one makes pressure; the other suction. 
The degree of movement necessary for the age period is 
marked upon the piston. 

The lung motor may be used in cases of asphyxia from 
gas or smoke, from drowning or hanging, in which respiration 
is arrested by obstruction of the trachea. 

The method of continuous intratracheal insufflation of air 
described by Meltzer and Auer, which has been elaborated by 
Elsberg for ether anesthesia, would seem a valuable form of 
artificial respiration if the apparatus were available (p. 229) . 

Aspiration. — This procedure is adopted to remove fluid from 
a closed cavity without the admission of air, and the instru- 
ment which is employed to accomplish this object is known as 
an aspirator. The form of aspirator most generally employed 
is that of Potain. 

Potain's Aspirator. — This consists of a glass bottle, into the 
stopper of which is introduced a metallic tube, which is con- 
nected with two rubber tubes,* one of which is connected with 
an exhausting pump and the other with a delicate cannula 
carrying a fine trocar; the apparatus is provided with stop- 
cocks to prevent the admission of air (Fig. 150). In using 
this aspirator the air is exhausted from the bottle by using 
the air pump; the cannula enclosing the trocar is next pushed 
through the tissues into the cavity containing the fluid to be 
removed; the trocar is then removed, and upon opening the 
stop-cock the fluid is forced out of the cavity by atmospheric 
pressure and passes into the bottle or receiver. If the fluid 
contains masses of lymph or clots which block the cannula, 
interrupting the flow of fluid, a stylet may be passed through 
the cannula to free it from the obstruction. 

To diminish the pain produced in introducing the trocar 
and cannula the skin at the point to be punctured may be 
rendered less sensitive by holding in contact with it for a few 
minutes a piece of ice wrapped in a towel, or by the injection 



ARTIFICIAL RESPIRATION 



171 



of a local anesthetic. Care should also be taken to see 
that the trocar and cannula have been perfectly sterilized; to 
accomplish this they should be boiled for five minutes or placed 
in a 5 per cent carbolic solution for twenty minutes and soaked 
in sterile water before being used. Before introducing the 
trocar and cannula the operator should sterilize the skin at 
the seat of puncture by painting it with tincture of iodine 
and in its introduction should be careful to avoid injuring 
important veins, arteries or nerves. 



Fig. 150. 




Potain's aspirator. 



After removing the cannula the small puncture should be 
dressed with shreds of absorbent cotton held in place by 
collodion and a compress of sterile gauze held in place by a 
bandage or adhesive straps. 

The aspirator is frequently employed in cases of hydro- 
thorax, empyema and ascites, to evacuate the contents of 
abscesses in diseases of the hip and spine, and to remove the 
contents of a distended bladder until a more radical operation 
can be performed. It is also a valuable instrument for diag- 
nostic purposes, being frequently used to ascertain the charac- 
ter of the contents of deep-seated tumors containing fluid. 



172 MINOR SURGERY 

Exploring Syringe. — A glass barrelled syringe, to the nozzle 
of which are fitted sharp-pointed hollow needles of different 
caliber and lengths, is a most useful instrument for ex- 
ploratory aspiration. It should be sterilized by boiling; 
the skin should be sterilized by iodine. It is frequently used 
to ascertain the contents of inflammatory swelling or tumors. 
In effusions in the chest or the abdominal cavity, even after 
the abdomen has been opened and tumors exposed, it is 
often wise to use this instrument to ascertain the nature 
of their contents. It is well to use a small needle first, and 
if not satisfactory a larger one should be substituted; the 
smaller the puncture the less risk of leakage. 

The Stomach-tube. — This consists of a partially flexible 
tube about 28 inches in length and | inch in diameter, which 
is introduced while the patient is in the sitting posture, the 
head being thrown backward so as to bring the mouth and 

Fig. 151. 




The stomach-tube. 



gullet as nearly as possible in the same line (Fig. 151). The 
tube being warmed and oiled, the surgeon standing in front 
of the patient passes it directly back to the pharynx, 
taking care to keep the lip in contact with the posterior 
wall of the pharynx. It is then passed gently downward 
into the stomach. If any obstruction is met with in its 
passage it should be withdrawn a little and then pushed 
gently downward ; all manipulations should be made without 
much force to avoid perforating the wall of the esophagus. 

The introduction of the stomach-tube may be required for 
the evacuation of poisons from the stomach or to wash out 
the cavity of this viscus. It may also be used to introduce 
liquid nourishment into the stomach of patients who are 
unable or unwilling to swallow food. In introducing liquid 
nourishment a syringe or funnel is fitted to the free end of 
the tube, which has been passed into the stomach; the 
syringe or funnel having been filled with milk or beef tea or 



THE STOMACH-PUMP 



173 



broth, the contents are injected gently or allowed to run into 
the stomach. 

In cases of poisoning where it is desirable to withdraw the 
contents of the stomach and to wash out the organ, a stomach- 
tube and syringe may be employed; several syringefuls of 
warm water are first thrown into the stomach and then with- 
drawn by suction, but in such cases the use of the stomach- 
pump will be found more satisfactory. 

Lavage. — In the recently introduced method of treating 
disorders of the stomach by irrigation the introduction of a 
flexible rubber stomach-tube is required; the tube here 
employed is from 24 to 30 inches in length, and the fluid is 
introduced by means of a funnel attached to its free extremity 
or it may be attached to a stomach pump. 

Fig. 152. 




Stomach-pump. 



The Stomach-pump. — This consists of a brass syringe, the 
nozzle of which is connected with two tubes, one at the end, 
the other at the side. The passage of fluid through the 
nozzle is regulated by a valve controlled by a lever. The 
nozzle of the pump is attached to a stomach-tube and the 
end of the lateral tube is placed in a pan of warm water. By 
withdrawing the piston and opening the valve, water may be 
drawn from the basin, and by closing the valve and depressing 
the piston it is forced through the stomach-tube into the 



174 MINOR SURGERY 

stomach; when a sufficient quantity has been injected in this 
manner by reversing the action of the valve the fluid is drawn 
out of the stomach and discharged through the lateral tube 
into a basin. This manipulation is continued until the water 
returns clear and the stomach has been completely washed 
out. The stomach-pump shown in (Fig. 152) may also be 
employed. 

Esophageal Bougie. — This instrument — which may be 
passed through the esophagus into the stomach for the pur- 
pose of. diagnosis or for the purpose of dilating strictures of 
the esophagus — is employed in exactly the same manner as 
the stomach-tube, and, as in the case of the latter instrument, 
it should be introduced without the use of much force, as 
perforations of the esophagus have followed the forcible 
introduction of such instruments. 

The Rectal Tube. — The introduction of the rectal tube is 
best accomplished by placing the patient upon his left side, 
and the surgeon should introduce his index finger well oiled 
into the rectum and guide the tube upon this through the 
anus, when by gentle pressure it is gradually passed into the 
rectum; if a stricture exists in the rectum within reach of the 
finger the latter should be used to guide the tube through 
the opening in this ; if the tube becomes caught in a transverse 
fold of the mucous membrane and doubles upon itself it should 
be withdrawn and a fresh attempt made to pass it. In pass- 
ing a rectal tube all manipulations should be made with 
extreme gentleness, as it has been shown that its passage is 
not without danger, perforations of the intestine having fol- 
lowed its use in some cases. In cases of stricture of the 
rectum high up the operator has to depend upon the sense 
of resistance experienced in passing the tube and in such cases 
the manipulations should be most carefully made. When 
the rectal tube is employed to introduce fluid into the large 
intestine the fluid may be introduced by means of a syringe, 
or by pouring it into a funnel attached to the free end of the 
tube, or by attaching the tube to a fountain syringe, thus 
allowing the liquid to pass slowly into the intestine. 

The rectal tube is often employed with good results in irri- 
gating the large intestine, relieving the intestine of flatus, 
and in introducing water or oil into the intestine in cases of 



EN EM AT A 175 

intestinal obstruction, and in those cases where the obstruc- 
tion results from intussusception or fecal accumulations its 
use will often prove satisfactory. 

Rectal Bougies.— These instruments are made of India- 
rubber or the same material as the English flexible catheter 
and are of various sizes. They should first be oiled, and are 
introduced in the same manner as the rectal tube. They are 
generally employed in cases of stricture of the rectum, and 
should be introduced with great care to avoid perforating 
the wall of the rectum; this accident has occurred in the 
hands of skilful surgeons. A very satisfactory substitute for 
a rectal bougie is a tallow candle, one end of which is melted 
or rubbed down to conical shape. 

Enemata. — These may be administered by means of an 
ordinary syringe, or by means of a gravity or fountain syringe; 
the precautions which should be observed are to introduce the 
nozzle of the syringe gently and in the right direction, as per- 
foration of the lower portion of the rectum has taken place 
from careless and forcible introduction of the nozzle of the 
enema syringe; the fluid should also be injected slowly, as by 
so doing there is less resistance and less tendency for the 
patient to pass the fluid before the desired quantity has been 
introduced. 

The enema most commonly employed to empty the lower 
bowel is made by adding a tablespoonful of sweet oil and 2 
teaspoonfuls of spirit of turpentine to 1 or 2 pints of warm 
water in which a little Castile soap has been dissolved; warm 
water and sweet oil are also frequently used for the same 
purpose. 

Glycerin Enema. — One or 2 teaspoonfuls of glycerin injected 
into the rectum or a suppository made of glycerin will often be 
found an efficient substitute for the larger enema of water. 

Nutritious Enema. — When it is found necessary to resort to 
feeding by the rectum the substances employed should be 
injected into the rectum by means of a syringe and care 
should be taken that the quantity is not too large and that it 
is of such a nature as not to cause irritation of the walls of the 
rectum or it will not be retained; 2 to 4 ounces in the case of an 
adult is generally a sufficient quantity to inject at one time. 

Peptonized milk or beef juice, or the yolk of an egg beaten 



176 MINOR SURGERY 

up with milk, is often employed, and any unirritating drugs 
may be mixed with the enema and administered at the same 
time. Gloucose solution (6-10 per cent) is excellent. 

Vaccination. — This is a minor surgical procedure which 
every physician is called upon to perform. The surface may 
be prepared for the reception of the lymph by abrading the 
skin at one or two points with a dull lancet or by making 
several superficial incisions with a knife, or by scratching the 
surface of the skin with the ivory point charged with lymph, 
in lines with crossing lines, cross-scratch, until a little serum 
exudes. It is not advisable to draw blood which washes away 
the lymph and for this reason we prefer the abraded surface 
made by the dull knife or the ivory point. 

The lymph used may be the humanized or the bovine. 

Bovine lymph or virus, which is now most generally em- 
ployed, is taken from the vaccine vesicles upon. the udders 
and teats of heifers. The lymph may be mixed with steril- 
ized glycerin and placed in fine glass tubes which are sealed; 
or ivory points or quills are dipped in the lymph and allowed 
to dry, and in using these they are dipped in water for a 
moment to moisten the lymph before being applied to the 
abraded surface. The ivory point is one of the most con- 
venient means of vaccination, as the surface may be abraded 
with it before the lymph is applied. 

It has recently been advised that antiseptic precautions be 
exercised in performing vaccination, and although all of the 
details cannot be carried out we have found that the exercise 
of care as regards cleanliness of the surface has been followed 
by much fewer inflammatory complications in vaccination 
wounds. 

The surface to be abraded, usually the left arm below the 
deltoid, is first washed with soap and water, then with a 
1 : 2000 bichloride solution, or with alcohol and finally washed 
with sterilized water. Two points of this surface, 1 inch 
apart, are then abraded by using a knife which has been 
washed or dipped in boiling water, or by using the ivory point 
which has been dipped in water that has been boiled and 
cooled. When the surface has been prepared in the manner 
described the moistened virus is rubbed upon it and allowed 
to dry. Vaccination upon the leg, which is practised by some 



HYPODERMIC INJECTIONS 



177 



physicians to prevent the scar from showing, I think is not to 
be recommended, and I never practise it in this situation, as it 
is more dim cult to keep this part at rest. 

Hypodermic Injections. — The syringe used to make hypo- 
dermic injections is provided with a perforated needle, which 
is passed into the cellular tissue (Fig. 153). Care should be 
taken to see that the instrument and needle are perfectly 
clean before being used ; they should be rendered aseptic by 
soaking them for a few minutes in boiling water or in a 5 per 
cent carbolic solution. Hypodermic injections are generally 
made into parts in which the cellular tissue is abundant, and 
great care should be observed to avoid introducing the needle 
into a large vein or artery, as by neglect of this precaution 
serious symptoms have resulted from the drug being thrown 
rapidly into the circulation instead of being slowly absorbed 

Fig. 153. 




Hypodermic syringe and needles. 



from the subcutaneous cellular tissue; injury of superficial 
nerves should also be avoided. Care should also be taken to 
see that the solutions employed are sterilized if possible, and 
freshly made solutions should be preferred. 

To avoid using solutions for hypodermic use which undergo 
change in keeping, it will be found convenient to use the 
compressed pellets which are prepared by manufacturing 
chemists, the alkaloids being compressed with a little sulphate 
of sodium which increases their solubility, the solution being 
prepared with boiled water just before being used. 

The portions of the body usually selected for hypodermic 
injection are the outer surface of the thighs or arms and the 
anterior surface of the forearms. In making a hypodermic 
injection the syringe is charged and the needle is fastened 
to the nozzle of the syringe; the skin is next pinched up and 
the needle is quickly thrust through this into the cellular 
12 



178 



MINOR. SURGERY 



tissue (Fig. 154); the syringe is then emptied by pressing 
down the piston, and when the cylinder is empty the needle 
is withdrawn. 

Injection of Antitoxins. — In the treatment of diseases such 
as diphtheria, anthrax, septicemia, pneumonia and tetanus 
by the injection of serum, the hypodermic method is made 

Fig. 154. 




Method of giving a hypodermic injection. 

use of; in using antitoxin injections in diphtheria the dose of 
the antitoxin is proportionate to the age and weight of the 
patient as well as to the severity and duration of the disease. 
A child, aged three years, should be given 2000 units; an 
adult, not less than 3000 units; and the injection should be 
repeated in twelve to twenty-four hours. In severe cases 
much larger doses should be given. The immunizing dose 



Fig. 155. 




H. K. MULFORD CO., PHILADA. 

Syringe for serum injection. 



of antitetanic serum is 1500 units. When the disease has 
developed large amounts of the serum should be injected 
directly into a vein and into the spinal canal. Before em- 
ploying the injection the skin should be sterilized and the best 
variety of syringe to employ is one holding about 20 cc 
(Fig. 155). 



THE WASSERMANN TEST 179 

The various antitoxins are now furnished in glass tubes, 
with a needle and piston. The tube contains the approxi- 
mate dose. By removing the plug at one end of the tube, 
inserting the piston, removing the tapering end of the tube 
and attaching the needle, the injection may conveniently be 
given. 

It is well to have the needle connected with the syringe by 
a short rubber tube so that the needle will not be broken if 
the patient struggles. The injections are usually made below 
the angle of the scapula or in the lumbar region and the serum 
is introduced slowly to avoid local reaction. 

Coley's Fluid. — This fluid, which consists of the mixed tox- 
ins of Streptococcus erysipelatis and Bacillus prodigiosus, has 
been employed in the treatment of sarcoma with some success. 
It has been especially used in inoperable sarcomata of the 
abdomen and recurrent and secondary sarcomata of bone. 
Two to 10 minims are injected hypodermically at intervals of 
a few days, depending upon the amount of constitutional reac- 
tion produced, and the dose is gradually increased if the 
patient bears it well. The treatment should be continued for 
some weeks until it is shown that no results are obtained or 
the growths are diminishing. 

The Wassermann Test. — The Wassermann reaction is a test 
used in the diagnosis of syphilis. Its principles are compli- 
cated, and it can be made only in well-equipped laboratories 
by technicians of experience. It depends upon the behavior 
of a so-called hemolytic system. In a hemolytic system, 
hemolysis, or solution of red blood cells, is due to the action 
of the hemolysin upon the red blood cell through the medium 
of a hypothetical substance known as complement which is 
present in all normal serum. Wassermann showed that 
extracts of syphilitic organs in the presence of the serum of 
a syphilitic possessed the power of combining with comple- 
ment, thus rendering it inert. Certain lipoidal bodies have 
the same property. Complement may be destroyed in serum 
also by a low heat which is insufficient to change the other 
properties of the serum. 

Employing these principles, the presence of syphilis is 
demonstrated in the following manner: The serum of the 



180 MINOR SURGERY 

person to be tested is heated to destroy complement. It is 
then mixed with the organ extract and with guinea-pig serum 
to furnish a known amount of complement which has been 
previously determined by titration. If the serum is syphil- 
itic a part or all of the complement thus added will be com- 
bined and rendered inert. In order to determine whether 
complement is present the red blood cells of some animal, 
usually the sheep, and a quantity of hemolysin are added. 
If the complement has not been previously exhausted by com- 
bination of the organ extract to be tested hemolysis will take 
place; if complement has been destroyed however, hemolysis 
will be partially or completely inhibited. This inhibition of 
hemolysis, therefore, becomes the indication of the existence 
of syphilis, and according to the degree of inhibition we say 
the test is weakly, medium or strongly positive, or for con- 
venience it is usually designated Plus 1, 2, 3 or 4. 

If complete hemolysis occurs the test is negative. This is 
an extremely valuable test for syphilis, and especially so for 
control of results of treatment. It is not infallible. A nega- 
tive test may be found in latent syphilis, and positive reac- 
tions are sometimes obtained when there is practical certainty 
that syphilis does not exist or has never existed. 

A persistently positive reaction with certain variations of 
technic, which cannot be described here, are practically diag- 
nostic. The test is not usually positive until two or more 
weeks after the primary lesion. Under successful treatment 
it frequently becomes negative and is the most delicate indi- 
cation of complete cure. Wet nurses and prospective donors 
for blood transfusions should be tested by this method before 
being used. The test may be positive with spinal fluid in 
syphilis of the nervous system even when negative in the 
blood. 

Injections of Mercury in Syphilis. — Injections of mercury 
may be made into the subcutaneous tissue of the loins, but- 
tocks or scapular regions in the treatment of syphilis. Injec- 
tions may also be into the veins. The solution most com- 
monly used is a 1 per cent solution of the cyanide of mercury, 
20 minims being injected every day or on alternate days. 



INJECTION OF ARSPHENAMINE 181 

Injection of Salvarsan or Arsphenamine. — The researches 
of Ehrlich upon the action of the organic compounds of 
arsenic upon animals infected with parasitic protozoa induced 
him to use these arsenical compounds in the treatment of 
syphilis. 

Salvarsan, known also as "606," was the first drug em- 
ployed. It is a yellow crystalline powder containing about 
one-third of its weight of arsenic. Neosalvarsan, a more 
recent preparation of Ehrlich's is a combination of salvarsan 
with formaldehyde sulpholoxylate. 

Arsphenamine, an American preparation, is very exten- 
sively employed at the present time. 

They are powerful antiseptics and destroy syphilitic para- 
sites with which they are brought in direct contact. They 
have no eliminative action like the iodides, and are useless 
for lesions to which they cannot be conveyed directly through 
the blood stream. They are best administered by intraven- 
ous injection; the solution may be injected into the vein by 
a puncture through the skin with a hollow needle or the vein 
may be exposed and opened with full antiseptic precautions 
as in the transfusion of blood or saline solution. The usual 
dose of salvarsan is 0.6 gm. in 40 cc of freshly prepared 
sterilized saline solution. This mixture is rendered alkaline 
by adding drop by drop 1 cc of a 15 per cent solution of 
sodium hydrate, constantly agitating the mixture. Saline 
solution is next added to make 300 cc. Each 50 cc of the 
mixture contains 0.1 gm. of salvarsan. 

Clinical experience has proved these arsenical compounds 
to be of great value in the treatment of syphilis, being abso- 
lutely curative in some cases, shown not 'only by rapid and 
permanent disappearance of the symptoms, but also by the 
persistently negative Wassermann tests. 

A number of injections are required and should be given 
in courses with an interval of rest. 

Salvarsan injections cause the rapid disappearance of the 
lesions in syphilis, but if they are not continued at intervals 
or mercury or iodides not given relapses are almost certain 
to occur. 

The best results have been obtained by the more or less 



182 MINOR SURGERY 

prolonged use of mercury and the iodides after the injections 
of salvarsan. 

After the infusion of salvarsan, patients within a few hours 
sometimes develop gastric irritation, high temperature, weak- 
ness and vertigo and loose stools. Death has followed the 
injection of salvarsan in a number of cases. 

Exploring Needle. — This consists of a fine-grooved needle 
fitted into a handle (Fig. 156), which is introduced into 

Fig. 156. 



Exploring needle. 

tumors or swellings to ascertain the nature of their contents, 
its use is often of service for purposes of diagnosis. The 
exploring trocar (Fig. 157) is employed for the same purpose, 
or the needle of the hypodermic syringe or a fine needle 
attached to an aspirator may be used for a like purpose. 
When either the exploring needle or trocar is employed care 
should be taken to see that it is rendered perfectly aseptic 
before being used; otherwise its employment is not without 

Fig. 157. 



Exploring trocar. 

danger for we have seen the introduction of an exploring 
needle into an effusion in a joint for diagnostic purposes 
followed by infection and destruction of the joint, which 
subsequently necessitated its excision. 

Skin Grafting. — This is a surgical procedure which may 
employed to insure healing or to hasten cicatrization where 
large granulating surfaces are exposed, such as result from 
extensive operations and from burns. 



SKIN GRAFTING 183 

The operation consists in applying shavings of the epider- 
mis, or of the epidermis and cutis together, to the granulating 
surface and holding them in contact with it for a few days; 
the grafts often seem to disappear, but at the end of a few 
days, if the part is closely inspected, bluish-white points 
will be seen to occupy the positions at which the grafts were 
applied, which become converted into isolated islands from 
which the healing process rapidly extends. To have a suc- 
cessful result follow the use of skin grafts the granulating 
surface should be healthy, and its surface as well as the sur- 
rounding skin rendered aseptic and the grafts should be 
applied at a number of points. 

When it is possible grafts should be taken from the body 
of the patient. Autografts are more likely to grow than 
those taken from another person. Skin containing hair is 
not suitable for grafting as it is difficult to sterilize and is not 
so likely to grow, and deformity may result from the repro- 
duction of hair upon the grafts. Grafts are usually taken 
from the skin of the outer surfaces of the thighs or arms or 
from the lateral thoracic or abdominal walls. 

Skin grafting may be employed to cover fresh raw surfaces 
at the time of operation or later when the surfaces are covered 
with granulations. 

Three methods of skin grafting are usually employed, 
known as the Reverdin, Thiersch and Wolfe-Krause methods. 

Reverdin's Method. — In applying skin grafts by this 
method, small portions of the skin are raised on the point of 
a needle and cut off with a sharp scalpel or scissors and trans- 
ferred immediately to the granulating surface which has been 
previously prepared. The graft is applied to bring the raw 
surface in contact with the granulations and is pressed firmly 
upon them, a sufficient number of grafts are applied to par- 
tially cover the granulating surface. As the individual grafts 
are small, this method of skin grafting is not employed where 
the raw or granulating surface is extensive. After the skin 
grafts have been applied the entire area is covered with a layer 
of wide meshed paraffine gauze over which is placed a pad of 
gauze moistened with saline or 2 per cent sodium bicarbonate 
solution. The dressing need not be disturbed for five or six 



184 



MINOR SURGERY 



days, at which time inspection will show that many of the 
grafts have taken. 

The surface from which the grafts are to be taken should 
also be rendered aseptic and the skin should be removed by 
scissors or by a sharp razor, or by raising the epidermis with 
a needle or with forceps and cutting out a small portion with 
a sharp scalpel. 

Thiersch's Method. — In skin grafting, according to this 
method, the surface of the ulcer is rendered aseptic, and all 
antiseptics are washed away with sterilized salt solution. 
The surface of the ulcer is next curetted to remove soft 
granulations, and it is then irrigated and covered with a 
moist compress to control bleeding. Long strips of the epi- 
dermis with only the superficial layers of the cutis are then 
removed from a surface — which has been rendered aseptic — 
by means of a razor or section knife while the skin is made 
taut; the use of McBurney's hooks (Fig. 158) will facilitate 

Fig. 158. 




McBurney's hook. 

the removal of the grafts. Each graft should be as long and 
broad as possible, and when cut it should be floated from 
the section knife upon the prepared surface of the ulcer by 
a stream of salt solution and gently pressed into place. After 
a sufficient number of grafts have been applied, strips of pro- 
tective or a layer of paraffine gauze are laid over the surface 
of the grafts, and over these is placed a compress moistened 
with salt solution, and a few layers of sterilized gauze and 
cotton are next applied over this, and the dressing is held in 
position by a bandage. 



BONE TRANSPLANTATION 185 

The dressings need not be removed for a week or ten days 
and a second dressing should be applied in the same manner 
until the grafts have become thoroughly vitalized. The skin 
of the bellies or backs of frogs, or the hairless skin of young 
animals has been used in place of human skin, but has not 
proved satisfactory. 

Wolfe -Krause's Method. — Skin grafting is sometimes ac- 
complished by immediately applying an isolated piece of 
skin to a raw surface to fill a gap; the graft in such cases 
includes the whole thickness of the skin, but has all of the 
cellular tissue removed from it, and should be cut one-third 
larger than the gap to be filled to allow for the shrinking after 
its removal, it is secured in position by sutures. 

The wound should be dressed as in the other methods of 
grafting and the dressings should be covered with a hot-water 
bag for a few days. This is the best method of grafting for 
a raw surface after operation if it can be covered by a single 
graft. If the graft is more than 7 cm. in diameter it is not 
likely to retain its vitality. A modification of this method, 
which is often successful in granulating surfaces, is to cut 
numerous grafts from 1 to 2 cm. in diameter and apply them 
to the granulating surface not more than 1.5 cm. distant from 
each other. The wound should be dressed as previously 
described. 

Bone Transplantation or Bone Grafting. — This procedure 
is resorted to to replace portions of bone which have been 
lost by disease or operation, to fill up cavities in bone, or 
for immobilization of the spine in tuberculosis, in ununited 
fractures to bridge the gap and give fixation and act as an 
osteoconductive tract to promote bony union. It consists in 
transplanting a portion of bone from one part of the body 
to another and bringing it in contact with living bone ; the 
bone transplanted should if possible have the periosteum 
retained, but one without periosteum may be successfully 
transplanted. It is essential that the graft be removed from 
the same individual. The bone transplant is usually taken 
from the subcutaneous surface of the tibia, a portion of a 
rib or parts of other bones may be used. 

Albee has developed a very satisfactory technic for bone 



186 MINOR SURGERY 

transplantation or bone grafting, which can be employed in 
fractures, ununited fractures and tuberculosis of the spine 
(p. 526). 

The transplant, according to Murphy, being brought in 
contact with living osteogenetic bone at one or both ends, 
always becomes united to the living bone and acts as a 
scaffolding for the reproduction of new bone of the same size 
and shape as the transplanted fragment. The transplanted 
fragment gives mechanical support to the capillaries and 
bloodvessels, with their living osteogenetic cells, as they 
advance from the living bone at both ends of the transplant. 
New lamella? are deposited around the new capillaries so that 
bony union is actually formed before the transplant is entirely 
absorbed and replaced by new bone. 

The transplanted fragment is always ultimately absorbed. 
Murphy holds that the regenerative cells are supplied entirely 
from the osteogenetic cells of the capillaries from the living 
bone, and that the graft is absolutely necessary for the 
regeneration. 

The surface of bone covered with periosteum should not 
be brought in contact with living bone, as the Haversian 
vessels of the living bone do not penetrate the fibrous perios- 
teum of the transplant and regeneration does not take place. 

To obtain regeneration of bone in bone transplantation it 
is essential that the wound is aseptic. 

The technic of the operation is as follows : The bone sur- 
faces to which the transplant is to be applied are freshened 
with saw or chisel and a cavity is made in each fragment with 
a reamer of sufficient size to accommodate the ends of the 
transplant. An accessible bone of the same individual, the 
anterior edge of the tibia, .the upper edge of the ulna or the 
upper portion of a rib is next exposed, and a section of bone 
of the desired size is removed with a saw and chisel. The 
size of the graft required depends upon the size of bones to 
which it is to be applied and the defect which it is desired 
to bridge. This transplant is then transferred to the bone 
surface prepared for it, the ends of the transplant being 
fitted into the cavities previously made, acts as a dowel 
and fixes the fragments. If additional fixation is required 






BONE WAX 187 

screws or a metal plate may be employed. The wound is 
next closed by deep and superficial sutures without drain- 
age, and the part is immobilized by the application of a 
plaster-of-Paris dressing. 

In the case of parallel bones, such as the tibia and fibula, 
where there has been a loss in substance of the tibia, the 
fibula has been divided on a line with the lower end of the 
tibia, and after freshening the end of the tibia the upper end 
of the lower fragment of the fibula is shifted over to the tibia 
and secured to it by sutures. 

Decalcified Bone Plates or Chips. — These were formerly 
used in filling up the cavities resulting from extensive re- 
movals of bone by injuries or in the operation for necrosis or 
caries. They were not usually successful on account of the 
difficulty of completely sterilizing the bone cavity. 

Bone Wax. — This material, devised by Mosetig-Moorhof, 
is employed to fill up cavities in bone remaining after the 
removal of diseased bone or tumors of bone. The wax is pre- 
pared by melting together iodoform, 20 parts; spermaceti, 40 
parts; and oil of sesame, 40 parts. This preparation is 
heated to 50° C. and is poured into the cavity, which has 
been rendered sterile and dry, and when the wax has become 
firm the soft tissues are sutured over it. The cavity may be 
dried and sterilized by the hot-air blast or it may be seared 
with the actual cautery, or swabbed with formalin and dried 
with sterile gauze. Very good results have been obtained 
by the use of this preparation, although symptoms of iodo- 
form poisoning have been reported from its use. 

Moore has employed a bone wax containing iodine which 
he considers more satisfactory than that of Moorhof. It 
consists of iodine, 1 per cent.; olive oil, 2 parts; and sperma- 
ceti, 8 parts. The iodine is added after the spermaceti and 
olive oil have been mixed in a water bath, and heat should 
not be applied after the iodine has been added. The mass 
becomes solid at the body temperature. The bismuth emul- 
sion recommended by Beck may also be used in the same 
manner as bone wax in filling cavities in bone. This con- 
sists of bismuth subnit., 30 gm.; white wax, 5 gm.; vaseline, 
60 gm. 



188 MINOR SURGERY 

Thiersch grafts have also been employed with success in the 
treatment of open surfaces in bone cavities. The surface of 
the bone cavity is covered with Thiersch grafts and they are 
held in contact with the bone by a dry gauze tampon. 

Muscle grafting and nerve grafting are also occasionally 
resorted to to supply deficiencies in muscles or nerves, fresh 
muscle or nerve tissue being employed to fill up the gap. 
Fat is also used to fill cavities or other defects. 

Electrolysis. — Electrolysis, or the chemical decomposition 
induced by electricity is employed in surgery to destroy mor- 
bid products, tumors or exudations. For this procedure a 
galvanic or continuous-current battery is required, which is 
provided with electrodes and needles of suitable shapes. In 
applying electrolysis to a tumor, for instance, the needle con- 
nected with one of the poles of the battery is inserted into the 
tumor, and the other rheophore is applied to the surface of 
the body, or two fine needles, carefully insulated nearly to 
their extremities, are connected with both poles of the 
battery by conducting cords; these are introduced into the 
tumor and a weak current is allowed to pass. The strength of 
the current is gradually increased as the operation advances; 
the current is passed for fifteen or twenty minutes, and the 
procedure is repeated at intervals of several days until some 
decided change occurs in the tumor. 

Electrolysis has been applied with success in the treatment 
of aneurysm inaccessible to other operative procedures, in 
malignant growths, in nevi, goiters, cysts and hydatids. It 
is at the present time the most satisfactory method of remov- 
ing superfluous hairs from those portions of the body in which 
their presence causes disfigurement. 

Galvano-cautery. — Galvano-cautery batteries are so con- 
structed with plates of large size, placed closely together, 
that the internal resistance is reduced and a current is quickly 
obtained which will keep a metallic electrode at a white heat. 
The advantage in the use of this form of cautery is that the 
electrode can be introduced into the cavities of the body while 
cold and quickly heated to the desired temperature. The 
electrodes are made of various shapes and sizes, according to 
the object desired (Fig. 159). The galvano-cautery is applied 



THE CYSTOSCOPE 



189 



for the same purpose as the actual cautery; but, as previously 
stated, its use is more convenient in the cavities of the body, 
its action can be more easily localized and by its use hemor- 
rhage is avoided. It is frequently employed to destroy mor- 
bid growths in the nasal passages, the throat, vagina or uterus 
and also may be employed in the treatment of superficial 
external growths; in using it for the removal of growths from 
the mucous membrane, its application may be rendered prac- 
tically painless by previously thoroughly cocainizing the parts. 

Fig. 159. 




Electrodes for galvano-cautery. 



Faradization. — The application of electricity in this form is 
often employed in surgical affections; in cases of wasting of 
the muscles following fractures or sprains, in some forms of 
club-foot and in lateral curvature of the spine the judicious 
use of the faradic current will often be found to be followed by 
the most satisfactory results. The current is applied in such 
a manner as to bring about contraction of the affected or 
wasted muscles and thus improve their nutrition. 

The Cystoscope. — This is an instrument employed for 
ocular examination of the walls of the bladder, and is one of 
the most important and useful of the electric-lamp instru- 
ments. In females visual inspection of the interior of the 
bladder may be made by passing a narrow speculum into 
the bladder through the urethra with the patient in the 
knee-elbow or exaggerated lithotomy position, which allows 
the bladder to become distended with air as soon as the 
speculum is introduced. A cystoscope consists of a beaked 
sound in which there is a telescopic arrangement, by which 
the inner surface of the bladder is viewed through a small 
window of rock crystal. The lamp is enclosed in the beak 



190 



MINOR SURGERY 



of the instrument and throws its light through another 
window, also of crystal, upon any part of the bladder wall. 
Before introducing the cystoscope the deep urethra may 
be anesthetized by an injection of 4 per cent eucaine solu- 
tion; in some cases a general anesthetic is required. The 
urine is drawn and the bladder irrigated with a boric-acid 
solution. If pus and blood are present in the urine the irri- 
gation is continued until solution returns clear. Six to 8 
ounces of the solution is next injected and allowed to remain 
as it is necessary that the bladder should contain this amount 

Fig. 160. 




Illumination of the wall of the bladder by the cystoscope. 



of clear fluid if a proper view of the walls is to be obtained. 
If the fluid is turbid or contains blood the view is very much 
obscured; if too little fluid be present in the bladder the beak 
of the instrument containing the lamp is likely to become 
buried in the folds of mucous membrane and the light will be 
cut off, and the mucous membrane may be burned. The 
bladder may be emptied of urine and distended with air 
which accomplishes the same purpose. The cystoscope (ster- 
ilized in formalin solution, as it cannot be boiled) is introduced 
and when its beak is within the bladder the current is turned 



CATHETERIZATION OF URETERS 191 

on and the operator proceeds to inspect the interior of the 
bladder. The ureteral orifices may be seen and the escape 
of urine, blood or pus from them observed. The condition of 
the vesical mucous membrane is carefully observed and foreign 
bodies, tumors or calculi or diverticula may also be located. 

Cystoscopes are also provided with slots through which, 
it is possible to insert delicate instruments to make appli- 
cations to ulcers, cauterize or excise tumors or locate and 
remove foreign bodies. In this manner catheters may be 
inserted into the ureters for the purpose of obtaining a 
separate specimen of urine from each kidney. A certain 
amount of practice is required to use the cystoscope properly 
and to recognize the appearance of the mucous membrane 
of the bladder in health and in its varied morbid conditions. 

The Urethroscope. — The urethroscope consists of a straight 
metal tube provided with an obturator of hard rubber, which 
projects slightly beyond the end of the tube. This tube is 
introduced into the urethra until the bladder is reached, when 
it is slightly withdrawn and the obturator removed. The 
instrument is then attached to the mirror of an electric lamp, 
by which a strong light is thrown into the tube, and as the 
tube is withdrawn the urethra is exposed to view. By means 
of the urethroscope a very accurate inspection of all portions 
of the urethra can be obtained. 

The Panelectroscope. — This instrument, introduced by 
Leiter consists of an electric lantern with tubes and a mirror. 
The light from a small incandescent lamp is projected by 
the mirror along the tube which is inserted into the part to 
be examined. Tubes of various sizes are adapted to the 
instrument. It is employed for endoscopy of the urethra, ear, 
pharynx and stomach. 

Catheterization of the Ureters in the Males. — This is accom- 
plished by introducing the cystoscope and passing through 
slots in this instrument, ureteral catheters or bougies. As 
soon as the position of the ureteral orifices are located the 
catheters or bougies are introduced. By this procedure uni- 
lateral or bilateral disease of the kidneys may be demon- 
strated as well as the condition of the ureters themselves. It 
is also useful in estimating the functional capacity of the 
kidneys. 



192 MINOR SURGERY 

The same instrument may be employed for the catheteriza- 
tion of the ureters in the female, but since the ureters are 
more accessible in the female, the direct or Kelly's method 
may be employed. The patient is placed in the dorsal 
position with the pelvis elevated in an exaggerated lithot- 
omy position, or in the genu-pectoral position which allows 
the bladder to become distended with air as soon as the spec- 
ulum is introduced; the external meatus is anesthetized by 
cocaine and the urethra is dilated to admit a cylindrical 
speculum 12 to 15 mm. in diameter. With the aid of a head 
mirror the interior of the bladder can be directly inspected. 
The opening of the ureter may be exposed by turning the 
speculum 30 degrees to one side and is recognized as a small 
depression, the mucous membrane being of a darker color 
than elsewhere. A delicate elastic catheter can be introduced 
into this opening, and by careful manipulation may be passed 
to the pelvis of the kidney. 

Estimation of the Functional Capacity of the Kidneys. — 
This is accomplished by chromo-ureteroscopy by means of the 
indigo-carmine test; 4 cc of a 4 per cent solution of indigo- 
carmine is injected into the muscles or intravenously and the 
cystoscope is introduced. This solution stains the urine blue 
if the kidneys are healthy. Stained-blue urine should be 
observed to escape in less than nine minutes; non-appearance 
in the urine of the blue-staining in twenty minutes indicates 
serious incompetency of the kidneys. Or the ureters may be 
catheterized and the urine collected from each kidney sepa- 
rately tested . The phenolsulphonephthalein test may also be 
used as described by H. H. Young: The patient is given 
three glasses of water to drink and is then catheterized and 
the bladder washed out, and 1 cc of fluid containing 6 mg. of 
the drug is injected intramuscularly or intravenously. The 
time of the appearance of the first faint pinkish tinge as the 
urine escapes from the catheter into the test-tube, made 
alkaline by adding 1 drop of 25 per cent NaOH solution, is 
noted at the beginning of the test. In healthy patients the 
drug appears in the urine in about seven minutes after it is 
administered ; 40 to 60 per cent is excreted in the first hour 
and from 20 to 25 per cent in the second hour. 



ARTIFICIAL RESPIRATION 19 

Direct Laryngoscopy, Bronchoscopy, Esophagoscopy and 
Gastroscopy. — These are procedures using self-illuminated 
tubes which serve as specula for endoscopic examination and 
treatment of the interior of the larynx, bronchi, trachea, 
esophagus and stomach. 

The perfection of the technic and the elaboration of the 
instruments employed in this procedure are due to the genius 
of Chevalier Jackson. The endoscopic tubes are without 
lenses, are straight and rigid instruments used as other 
specula to displace tissues that obstruct direct vision or draw 
tissues to he inspected into a new position into the line of 
sight. 

Through these tubes many of the most ingenious instru- 
ments, such as forceps, sponge-holders, loops, hooks, bougies, 
etc., are used for various procedures such as the removal of 
foreign bodies — pins, tacks, pieces of bone, safety-pins, 
needles, coins and staples— dilatation of structures, diagnosis 
of disease by inspection and removal of tumors and specimens 
of tissues for examination. By the use of instruments 
devised by Jackson it is possible in skilful hands to change 
the position of foreign bodies so as to make their withdrawal 
possible and safe, to close an open safety pin, to change the 
position of a pin or staple so that the point cannot interfere 
with its removal. 

Jackson, in the use of the bronchoscope, laryngoscope or 
esophagoscope, does not use an anesthetic. Even in children 
in dyspnea general anesthesia is absolutely contraindicated. 
In adults he uses a hypodermic injection of a full dose of 
morphine to lessen the cough reflex. He paints the surface 
of the pharynx with a 10-gr. solution of cocaine. 

Jackson states that these instruments can be passed into 
any patient who is able to open his mouth. In the introduc- 
tion of these instruments the patient is placed upon a table 
and his head brought beyond the edge so that the middle 
of the scapula rests upon the edge of the table; the head is 
held by an assistant who can move it as directed by the 
operator. The instrument is passed into the larynx if inspec- 
tion of this organ is desired, and deeper into the trachea or 
a bronchus if these parts are to be inspected. 
X3 



194 



MINOR SURGERY 



In Jackson's clinic, bronchoscopic removal for foreign 
bodies has been successful in 98 per cent, of the cases. In 
386 cases there were 6 failures to remove, and the mortality 
was 1.7 per cent. To use these instruments with success a 
considerable amount of practise is required. 



Fig. 161. 




Bronchoscopy. (Ashhurst.) 



Massage. — Massage consists in a variety of manipulations, 
such as pinching up the integument and muscles and 
rolling them between the thumb and fingers; in stroking or 
rubbing the surface with the palm of the hand from the 
periphery toward the center, to empty the distended veins 
and lymphatics; rubbing the parts circularly with the extrem- 
ities of the fingers and thumbs or the palms of the hands. 
Kneading of the parts is another method of practising mas- 
sage. Massage may also be practised by tapping the surface 
of the affected part more or less forcibly with the tips of the 
fingers held in a row, or with the ulnar border of the hand 
or the palm of the hand. Before applying massage to an 
affected part, if there be a heavy growth of hair, it should be 
shaved off; otherwise the manipulation may give the patient 
pain and irritation of the hair follicles resulting in abscesses 
will be apt to occur. The part should also be rubbed over 
with olive oil, vaseline or cacao butter before and during the 
manipulations. 

Massage is employed often with advantage in the treatment 



APPLICATION OF HOT AIR 195 

of sprains and strains in their subacute and chronic stages. 
Lucas-Championniere advocates and practises immediate and 
continuous massage in the treatment of fractures. It will 
also be found of great service in the later treatment of fract- 
ures involving the joints or their vicinity in restoring the 
motion of the parts as well as in improving the nutrition of 
muscles which have become wasted from disuse. 

Passive Motion. — This manipulation consists in alternately 
flexing and extending or rotating the limb to imitate the nor- 
mal joint movements. The motions should be carefully prac- 
tised and in cases of fracture near joints they should not be 
undertaken, as a rule, until there is firm union at the seat of 
fracture; if for any reason passive motion is made use of 
before this time the fragments should be firmly supported 
while it is being employed. Other forms of massage, such as 
stroking and kneading, may be employed in conjunction vith 
passive motion in the treatment of the stiffness of joints 
resulting from fractures, dislocations and sprains; passive 
motion applied in this manner in conjunction with baking, 
will often restore the function of a stiff joint more satisfac- 
torily and with less pain to the patient than the forcible 
manipulations which are sometimes practised under an 
anesthetic. 

Compression. — This is a. valuable means of diminishing swel- 
ling in the early stages of inflammation and of bringing about 
the absorption of the effusion in the later stages. It may be 
applied by means of compresses, bandages or strapping. 
Pressure applied in this manner is often employed in the treat- 
ment of injuries of the joints and bursse, and in chronic inflam- 
matory swellings. It should be used with caution when the 
circulation in the tissues is impaired. 

Application of Hot Air or Baking. — The employment of a 
continuous hot-air bath has recently been advocated in the 
treatment of painful and partially anchylosed joints, syno- 
vitis, tenosynovitis and chronic rheumatism. In applying 
this method of treatment the limb is wrapped loosely with 
a number of layers of woolen blanket and introduced into a 
metallic cylinder, the temperature of which is raised to about 
300° F. The part is exposed to this temperature for twenty 



196 MINOR SURGERY 

minutes to one hour, and at intervals of twenty minutes the 
door is opened for a short time to allow the ingress of fresh 
air; if the part is perspiring it is wiped dry, for if moisture is 
present upon the limb scalds are likely to result. Electric 
bakers are now generally used, having superseded the bakers 
heated by gas. In using the latter the part is covered and 
several layers of woolen blankets and a metallic hood, which 
is adapted to different parts of the body, is placed over the 
parts and the current which operates the electric lamps is 
turned on. Under this form of treatment pain is often 
temporarily or permanently relieved, synovial effusions 
absorbed and adhesions are softened and disappear. Clini- 
cally it has been found that the best results following this 
method of treatment have occurred in painful and anchylosed 
joints following traumatisms; and although temporary 
improvement has occurred in rheumatic, gouty, tuberculous 
and gonorrheal affections of joints, permanent improvement 
is not so likely to result. Massage is frequently employed 
directly after the baking. Bier has also recommended the 
use of hot air to produce arterial hyperemia in the treatment 
of certain joint and neuralgic affections, the part to be treated 
being enclosed in specially devised hot-air boxes. 

Bier's Hyperemic Treatment. — Bier has called attention 
to the value of an artificial congestive hyperemia in the 
treatment of acute and chronic inflammations. He recog- 
nizes two kinds of congestion: (1) Arterial or active, pro- 
duced by him with hot air; (2) venous or passive congestion. 

Passive hyperemia may be caused by : (a) suction and (6) 
by constriction. To produce passive hyperemia by suction 
a glass vessel or cup is applied to the skin with a rubber bulb 
or suction pump attached to rarify the air within. The cups 
are now made of various sizes and shapes to adapt themselves 
to all surfaces of the body (Fig. 162). In applying this 
method the procedure should not cause pain and the suction 
should be intermittent. The patient is the best judge as to 
the amount of suction. If the patient complains of pain 
from the suction it is excessive and a lesser degree should be 
employed. If the suction is not intermittent but little benefit 
is derived. The cup is applied for three or four minutes, then 



BIER'S HYPEREMIC TREATMENT 



197 



renewed for one or two minutes and this procedure is repeated 
at intervals for at least half an hour. 



Fig. 162. 




Suction cup applied. 
Fig. 163. 




Rubber band applied to the arm to produce passive hyperemia. 

This method of artificial hyperemia is employed with good 
results in abscesses, acute or chronic, enlarged or inflamed 



198 MINOR SURGERY 

lymphatic glands, furuncles, carbuncles and many other 
localized inflammatory conditions. 

If pus is present a small incision should be made and the 
subsequent suction favors its escape. 

Passive hyperemia by constriction is produced by placing 
a thin rubber band or tube around a part and thus producing 
a congestion of the parts distal to it (Fig. 163). The com- 
pression should be just sufficient to produce a reddish-blue 
coloration of the skin, but never whiteness, beyond the point 
of constriction. It is especially applicable to the extremities. 
The arterial pulse should not be interfered with and should 
be as free as that upon the opposite limb. The temperature 
of the constricted part should be the same as the correspond- 
ing part on the other limb. 

The constriction should not cause pain in the congested 
area. It should be noted that in acute inflammatory affec- 
tions slight pain and throbbing is experienced even if the 
constriction is not too thoroughly applied. This usually dis- 
appears in from five to ten minutes. 

By rubbing the parts active hyperemia should be produced. 

When applied above wounds serum is poured out which 
improves the drainage and escape of pus. 

When edema appears the treatment should be suspended 
and not resumed until it disappears. 

If the part is edematous before the treatment is begun 
multiple incisions should be made before this is instituted. 

The case should be under careful observation during the 
course of treatment and if any of the following signs appear 
it is evident that the compression is not accurate : 

1. If the parts become very cyanotic. 

2. Marked pain and discomfort. 

3. Coldness of the part beyond the point of constriction. 

4. Pulse diminished in force or lost. 

5. Development of edema. 

6. Non-appearance of active hyperemia upon rubbing the 
part. 

The duration of treatment in acute cases should be short. 
Half an hour to an hour three or four times a day at intervals 
for twenty-four hours. It has been followed by good results 



ROENTGEN RAYS 199 

in acute pyogenic infections. It has been employed in 
wounds of the extremities and inflammation of joints with 
most satisfactory results. Abscesses, if present, should be 
incised, but drainage should not be introduced. Bandages 
should be removed before the constriction is applied to per- 
mit of swelling of the congested part and not interfere with 
drainage. 

In chronic cases the constriction should be applied for a 
longer period — from two to four hours a day for a number 
of days. Applied in this manner it has been employed with 
marked success in tuberculous affections of the bones and 
joints, chronic ulcers and in ununited fractures. 

Patients can be taught how to apply the constriction to pro- 
duce the proper amount of compression, and when so in- 
structed can use this method of treatment at their own homes . 

Active or Arterial Hyperemia. — This is produced by sur- 
rounding the affected area by hot air. This is accomplished 
by an apparatus which encloses the part, leaving an air space 
which is connected with an alcohol lamp. Various forms of 
hot-air boxes have been devised to fit different parts of the 
body. This form of treatment has been found especially 
serviceable in rheumatic joints, neuritis and neuralgia. 

SKIAGRAPHY, OR EMPLOYMENT OF THE ROENTGEN 

RAYS. 

Roentgen, in 1895, while investigating the cathode rays as 
developed in Crookes' tubes, discovered the energy which he 
named a:-rays. The rays are invisible, but have great power 
of penetration and pass through many substances which are 
opaque to sunlight and ordinary electric light. If the rays 
are intercepted by a body not readily permeable, which is 
placed between the Crookes' tube and a dry photographic 
plate, a shadow will be formed and an impression of this 
shadow will be formed upon the plate. Such a shadow is 
known as a roentgenograph. The fluoroscope consists of a 
fluoroscope screen, which is so placed that the rays emana- 
ting from the Crookes' tube and passing through any inter- 
cepted substance to be studied are reflected directly upon it. 



200 



MINOR SURGERY 



If the body is more or less resistant the observer can see it 
clearly through the skin and subcutaneous tissue. 

The time of exposure to the rays varies with the strength 
of the current and the thickness of the tissues. The exposure 
is usually from a few seconds to a few minutes. The tube 
should not be placed too near the surface of the body, and 
the exposure should be as short as possible. Exposures of a 
few seconds are now generally made. 

There occasionally develops after the use of the roentgen 
rays a peculiar disturbance of the tissues, probably trophic in 
nature, which is known as a roentgen-ray or a>ray burn. The 
skin, several weeks after exposure to the rays, may become 
ulcerated, the nails may be lost and a very intractable form 
of ulceration or gangrene develop. 

Fig. 164. 




Fracture of both bones of the forearm. (Ashhurst.) 

The roentgen rays are of great value in locating foreign 
bodies (Fig. 165), such as needles (Fig. 166), pins, bullets 
(Fig. 167) and pieces of glass if it is lead glass. A staple 
in left bronchus is shown in Fig. 168. They are employed 
also with advantage in locating mineral calculi in the 
bladder, ureter and kidney. They are also of value in 
locating purulent collections in the chest, subdiaphragmatic 
abscess and changes in the solid viscera. In carcinoma of 
the stomach and intestines or ulcers of the stomach or duo- 
denum roentgen-ray studies, after the administration of 
barium are of great value. They are also useful in detecting 
the presence of fractures and dislocations. In fractures 



ROENTGEN RAYS 
Fig. 165. 



201 




Roentgenograph of jackstone in the esophagus. (Newcomot.) 
Fig. 166. 











^*u"*s 










* 








. : , 




-i r 


'W 


* :- - " - ,> .''.*• 


',';- ',. 







Roentgenograph of needle in the hand. (Newcomet.) 



202 



MINOR SURGERY 



about the joints, epiphyseal separations and ununited fract- 
ures their use has proved most satisfactory. Roentgeno- 
graphs of fractures are shown in Figs. 169 and 170; of a bullet 
in the leg in Fig. 167; and of an epiphyseal separation of the 
humerus in Fig. 171. 

Fig. 167. 




Roentgenograph of bullet in the leg. (Newcomet.) 



Roentgen-ray and Radium Therapy. — Roentgen Rays. — 

Changes produced in the cells by roentgen rays are identical 
with those seen after the application of radium rays. They 
should only be applied by an expert roentgenologist. Their 
fiction appears to consist in stimulating an overproduction of 
abrous tissue by which the growth of cellular elements is 
arrested or abolished. 



ROENTGEN RAYS 



203 



These have been employed, where the cases are suitable, 
in the treatment of various ulcerations and tumors (both 
benign and malignant), in simple indolent ulcerations, uter- 
ine fibroids, enlarged glands and spleen associated with 
leukemia, warts, superficial epitheliomata about the face and 
hands and deep carcinoma or sarcoma where operation is 
not possible, as a preoperative and postoperative measure 
for prevention of recurrence in malignancy (especially in the 
breast, where it is often impossible to reach the deep glandu- 

Fig. 168. 




Roentgenograph of a staple in the left bronchus. (Newcomet.) 



lar involvements of the various lymphatic chains, in the 
axilla or neck or chest) where it is used previous to operation 
for its effects upon the lymphatics changing them into fibrous 
tissue, in diseases of the skin (eczema, psoriasis, sycosis, 
tinea tonsurans and affections of kindred nature). In 
diseases involving the hair the cure usually follows complete 
depilation. 

The " erythema dose" has been adopted as a standard and 
consists of that amount of exposure to the rays which will 
produce a slight redness of the skin. The principal factors 



204 



MINOR SURGERY 



involved in producing it depend upon the time of exposure, 
character of the ray, distance from the source and the filters 
employed. They must be modified according to the disease 
to be treated, as in superficial conditions, filters are not abso- 
lutely required. The reaction desired is a superficial one, 



Fig. 169. 




Roentgenograph of separation of upper epiphysis of the humerus. 

and will be produced in less time without them. In a deep 
"dose" heavy filtration (3 mm. or more) of aluminum or 
corresponding thicknesses of copper or other metal, must be 
used and the roentgen-ray tube should be further away from 
the surface of the skin and a generator of higher value should 
be employed. 



RADIUM 



205 



Radium. — Radium is used in the treatment of similar con- 
ditions, but has a much wider range of utility. It is usually 
employed by having one of the various salts, chloride or 
bromide, carbonate or sulphate, the last being very insoluble 
is preferred, placed in an applicator, the form depending upon 
the character of the disease to be treated. The "plaque," 
a piece of flat metal 1 or 2 cm. square, which has upon the 

Fig. 170. 




Multiple fracture of patella. (Newcomet.) 



active surface 5 or 10 mg. of radium salt incorporated in a 
varnish is employed in the treatment of various dermal con- 
ditions. It may be used in the treatment of nevi, especially 
the cavernous type. When the radium is to be placed in 
cavities it is employed in small tubes of glass covered by 
silver, aluminum, lead or platinum, containing from 5 to 100 
mg., estimated upon, the basis of radium element and when 



206 



MINOR SURGERY 



it is to be placed directly in the tissues hollow pointed tubes 
of steel or non-corrosive metal called " needles" will be found 
useful. In institutions having a sufficient amount of radium 
the "emanation" is employed. It requires extensive and 
complicated apparatus for its collection. Being a gas, it is 
possible to obtain a very large dosage in an extremely small 
capillary tube. These small tubes or "seeds" may be 






Fig. 171. 




Roentgenograph of separation of upper epiphysis of the humerus. 



imbedded directly in the tissue and not removed. As the 
activity of the radium products depend upon " active deposit" 
for their useful radiation, which is the gamma ray, it is 
immaterial if one employs a salt of radium, which has been 
properly aged, or the emanation. The latter being encased 
in a thin glass tube, permits the employment of considerably 
more of the beta radiation, which under some circumstances 



RADIUM 207 

has been found desirable. The alpha radiation is practically 
never used. 

When radium or emanation is used upon the surface of the 
body or when it is imbedded in tissues, the dosage is calculated 
in milligram hours for radium and millicurie hours for emana- 
tion, with notation as to the distance from the parts and the 
filters interposed. When a "plaque" is employed besides the 
beta and gamma rays there may be a small amount of alpha 
radiation present, but a thin piece of paper or rubber will 
remove it, and if the beta rays are not desired, practically 
all may be removed by employing a sheet of lead 1 mm. thick. 
Where the penetrating gamma rays alone are desired a small 
tube of lead or platinum with walls 1 to 3 mm. thick should 
be employed. These tubes are usually covered with rubber 
of about the same relative thickness to remove the secondary 
radiation which produces a degree of local irritation, due to 
the non-penetrating character of these rays. They are usu- 
ally spoken of as being soft rays and to a great extent worth- 
less compared with the hard rays which are penetrating. 
Radium has proved of value in carcinoma of the cervix uteri, 
as it brings the radiation in direct contact with the disease. 
It is not to be recommended for carcinoma of the body of 
the uterus. In carcinoma of the mouth, nose and other cavi- 
ties of the body good results have been obtained. Thorium 
salts may be employed in the same manner as those of radium 
except their life is shorter. 

In the employment of either roentgen rays or radium great 
care must be exercised not to produce a "burn" which will 
vary in degree depending upon the individual and the amount 
of radiation. In the milder form, the destruction of tissue 
may be slight, but healing is always slow and in those cases 
where there has been extensive destruction of tissue malig- 
nant disease may follow. In the more chronic effect of irradi- 
ation observed in those working about laboratories skin irri- 
tations, warts, keratoses, degenerations of the nails and hair 
of the hand, and, in more severe forms, malignancy follows. 
Varying degrees of telangiectasis often follow reactions upon 
the skin in the acute cases. 



208 MINOR SURGERY 

ANESTHETICS. 

Anesthetics are agents which temporarily abolish sensation, 
inducing a condition which is known as anesthesia, which 
should be distinguished from analgesia which is characterized 
by the abolition of pain. Anesthesia may be local, regional 
or terminal or general. 

Local Anesthesia. — This results from the direct application 
of anesthetic agents, such as cocaine or novocaine which are 
dissolved in saline solution, to nerve terminations, and causes 
analgesia of the tissues of a limited extent. Local anesthesia 
has the advantage over general anesthesia in that it is practi- 
cally free from anesthetic accidents, changes in the blood and 
the dangerous and uncomfortable symptoms which often 
follow general anesthesia. It has the disadvantage that the 
patient knows what is being done, and for this reason cannot 
be employed with satisfaction in children and nervous adults. 

The safety of local anesthesia compared with that of gen- 
eral anesthesia should influence the decision of the surgeon in 
the selection of an anesthetic for operations. Local anes- 
thesia is especially used in minor operations upon the fingers, 
toes, external genitals, superficial abscesses and tumors. 

Extensive operations can be performed in proper subjects 
under local anesthesia, even operations involving the vis- 
cera; its use, however, is usually restricted to minor surgical 
operations and debilitated cases in which the administration 
of a general anesthetic would be dangerous. The field of 
local anesthesia has been extended since it has shown that 
viscera innervated by purely visceral nerves are insensitive, 
and sensation exists only in those which receive branches from 
the somatic nerves. The parietal peritoneum is very sensi- 
tive to pain. The stomach, intestines, edge of the liver, 
gall-bladder, mesentery, bladder, kidney, lung, testicle and 
epididymis, except their coverings, are insensitive. These 
organs may be incised, sutured and handled without causing 
pain, but if traction is made upon them pain is produced by 
reason of their parietal attachments. The skin and mucous 
membrane, near orifices and connective-tissue, muscle and 
fascia are less sensitive. Bloodvessels are sensitive while 



ANESTHETICS 209 

attached to connective tissue. Bone, cartilage and tendons 
are insensitive, the periosteum and perichondrium are insen- 
sitive. Articular synovial membrane is very sensitive. It 
may be produced by the use of cold, a spray of ether, rhigo- 
lene, ethyl chloride or kelene, cocaine or eucaine hydro- 
chlorate, novocaine, holocaine hydrochlorate, stovaine hydro- 
chloride, or by Schleich's method of infiltration. 

Regional Infiltration or Terminal Anesthesia. — This is also 
sometimes described as neural anesthesia and results from the 
application of anesthetic agents to the nerve roots, nerve 
trunks or the spinal cord. The analgesia in this form of 
anesthesia extends from the point of application to the tissues 
supplied by the nerve or nerves and therefore is not limited 
in extent. 

General Anesthesia. — This is characterized by unconscious- 
ness, as well as abolition of sensation and may be induced by 
the administration of nitrous oxide gas, ether, chloroform, 
chloride of ethyl or kelene, A.-C.-E. mixture, C.-E. mixture, 
Schleich's anesthetic mixture or scopolamine. It may also 
be induced by a combination of these substances with nitrous 
oxide gas or oxygen. Hypnotism may also be employed to 
produce general anesthesia. 

Fig. 172. 




Application of rhigolene spray. 



Local Anesthesia. — Cold. — Local anesthesia may be pro- 
duced by the application of cold or freezing mixtures, either 
by a piece of ice or a mixture of ice and salt held in contact 
with the part for one or two minutes, or by directing a spray 
14 



210 MINOR SURGERY 

of rhigolene or sulphuric ether upon the surface of the part 
whose sensibility is to be obtunded (Fig. 172). 

Chloride of Ethyl or Kelene. — This substance is used also 
to produce local anesthesia and is conveniently furnished in 
glass tubes, one end of which is drawn out into a fine point 
and hermetically sealed or in a tube with metal cap which can 
be unscrewed. When used the end of the tube is broken off 
or the cap removed and a fine jet of ethyl is projected upon 
the part to be anesthetized, the warmth of the hand being 
sufficient to force the fluid from the tube; analgesia occurs 
in less than a minute. This form of local anesthesia is made 
use of in minor surgical procedures, such as aspiration, the 
opening of abscesses and the removal of superficial tumors. 

The objection to these methods of anesthesia consists in 
the pain which accompanies the thawing process and the 
interference with the vitality of the tissues by the freezing, 
which prevents prompt healing. 

Cocaine. — Local anesthesia produced by the employment 
of an aqueous solution of the hydrochlorate of cocaine 1 to 
100 to 1 to 200 or from J to 2 per cent is often made use of 
in minor surgical procedures. Solutions as strong as 10 or 
12 per cent were formerly employed, but experience has 
proved that there is always danger in the use of the stronger 
solutions of cocaine, so that it is now considered wise not to 
use one stronger than J or 2 per cent, as the full analgesic 
effect can be obtained by a solution of this strength. When 
mucous membrane is to be operated upon or growths removed 
from it, analgesia is produced by brushing over the surface 
with the solution of cocaine, or by applying to the part for 
a few minutes a compress of absorbent cotton saturated 
with it; in mucous cavities the latter method of application 
will be found most convenient. It is the most effective 
local anesthetic for mucous membranes. It is unwise to use 
over f gr. upon mucous surfaces, and not more than \ gr. 
should be used hypodermically; care should be taken that 
it does not enter a vein. In using a solution of cocaine to 
produce anesthesia in operations upon the eye a 2 per cent 
solution is dropped into the eye, and is repeated until 
analgesia is complete. 



ANESTHETICS 211 

In applying cocaine to the urethra a 1 to 2 per cent solu- 
tion is injected and is allowed to remain for two or three 
minutes; more than 1 or 2 gr. should not be injected at one 
time, as fatal results have followed the injection of larger 
quantities; this is especially the case in using cocaine in the 
urethra and the rectum and in these situations great caution 
should be exercised in its employment. 

When it is desired to produce analgesia of the skin or 
deeper tissues the application of cocaine to the surface is 
not satisfactory and it should in such cases be injected 
hypodermically into the deeper layers of the skin and into 
the cellular tissue of the parts to be operated upon; to avoid 
multiple punctures the needle is not completely withdrawn 
from the wound, but its direction is changed and the solu- 
tion is thrown into different portions of the tissues. It is 
not safe to inject more than ^ gr. of this drug. It is well in 
situations where it can be accomplished, as in operations 
upon the hands and feet, to cut off the circulation from the 
part to be operated upon by placing around it a rubber strap 
or tube which prevents rapid absorption of the cocaine into 
the general blood current. 

In employing any of these drugs hypodermically to avoid 
the pain following the puncture of the skin by the needle 
a minute drop of carbolic acid may be applied to the skin 
at the point of puncture which anesthetizes the skin so that 
the patient does not feel the insertion. 

Some persons have an idiosyncrasy for cocaine, and 
children seem more susceptible to its constitutional effects 
than adults. I have seen several instances in children in 
which marked symptoms of cocaine poisoning resulted from 
the application of a 4 per cent solution to the nasal mucous 
membrane. 

Cocaine poisoning is shown by restlessness, pallor, dryness 
of the mouth and weakness of the pulse; in dangerous cases 
there may be delirium or syncope. 

The treatment of cocaine poisoning consists in placing 
the patient in the recumbent position and the hypodermic 
injection of morphine, strychnine or ether. 



212 MINOR SURGERY 

Cocaine analgesia may be employed with advantage in 
minor surgical operations, such as amputations of the fingers, 
circumcision, opening of abscesses and removal of superficial 
tumors, but its utility is most marked in operations upon the 
eye and upon the mucous membranes of the nose, throat, 
rectum, vagina and urethra. Applied for a few minutes to 
the surface of an ulcer which is to be cauterized, it will render 
the operation almost painless. 

Eucaine Hydrochlorate (/3 Eucaine). — This drug, which 
possesses the same properties as cocaine as regards the pro- 
duction of analgesia, is employed as a local application to 
mucous surfaces and hypodermically in the deeper tissues 
to produce local and regional anesthesia. It has the advan- 
tage over cocaine that it can be used with safety in much 
larger quantities, as it is apparently free from toxic action. 
Kiessel states that 2 gm. have been injected without the 
production of toxic symptoms. It may be used in solutions 
varying in strength from 2 to 10 per cent, which may be 
sterilized by heating; a 2 per cent solution is that most usually 
employed hypodermically. It produces dilatation of the 
bloodvessels and may cause bleeding; this may be counter- 
acted by combining it with adrenalin. 

Novocaine. — This drug is similar in its action to cocaine, 
but is six times less toxic and is at the present considered 
the safest and most useful local anesthetic. 

It is not destroyed by boiling, but is injured by contact 
with free or carbonate alkalies, and should not be used with 
instruments boiled in soda solution. Its effect is not as 
lasting as that of cocaine, but combined with adrenalin it is 
very effective; it is less effective than cocaine in producing 
analgesia of mucous membranes. 

It does not cause irritation of the tissues or lower the blood- 
pressure. A 5 per cent novocaine solution has nearly the 
same specific gravity and freezing point as blood serum. It 
is used in a 2 to 4 per cent solution, or in a solution 1 to 200 
to 1 to 400. It may be combined with adrenalin in the 
following solutions. 



ANESTHETICS 213 



Solution No. 1: 



Solution No. 2: 



1-400. Novocaine grs. ii 

Saline solution f§iss 

Adrenalin (1-1000) 1Uv 

1-200. Novocaine grs. iv 

Saline solution §iss 

Adrenalin (1-1000) . . . . . . . lUv 

Solution No. 1 may be employed for infiltration anesthesia, 
and used in amounts up to 3 ounces. Solution No. 2 may be 
used for endoneural infiltration. 

Holocaine Hydrochlorate. — This drug, used in a 1 per cent 
solution, possesses as decided analgesic action as cocaine; 
it is also strongly bactericidal in its action. It may be used 
locally without producing constitutional symptoms, but can- 
not be used internally or injected into the tissues, on account 
of its marked toxic action. 

Stovaine Hydrochloride. — The drug is said to have analgesic 
properties equal to cocaine, and is only one-third as toxic. 
It is acid in reaction, may be boiled without injury and acts 
as a vasodilator. It has a marked action on motor nerves 
and paralyzes the muscles supplied by the nerves affected 
by it. It is dangerous as a spinal anesthetic and if used in 
the nose may cause troublesome bleeding. It may be dis- 
solved in warm water or salt solution. It is employed in the 
same manner as cocaine and eucaine to produce local anes- 
thesia. The solution used is 2 to 5 per cent. 

Apothesin. — The drug has a low toxicity and marked anal- 
gesic action in a 1 per cent solution. A combination of 
adrenalin (1 to 1000), 5 drops, to apothesin solution, 1 ounce, 
is used to produce infiltration analgesia. 

Quinine-urea Hydrochloride. — This is a double salt of qui- 
nine and urea. It is dissolved in salt solution or sterile water. 
A 0.25 per cent solution is effective in inducing prolonged 
local anesthesia. The anesthesia may last for hours. A 10 
per cent solution may be used externally or for anesthesia of 
mucous membranes. It has been used successfully in opera- 
tions for hernia and in operations upon the anus. It is said 
to be most effective and the prolonged anesthesia insures 
the patient comfort after the operation. In massive doses 
it tends to devitalize the tissues. 



214 MINOR SURGERY 

Procaine.— This substance recently introduced closely re- 
sembles novocaine in its properties and may be used for the 
same purposes and in the same strength as novocaine 
solutions. 

Adrenalin, Suprarenin, Epinephrin. — This drug is frequently 
used in combination with local anesthetic agents. It should 
be used in a strength of 1 to 10,000 and for injection of nerves 
or infiltration anesthesia in strength of 1 to 50,000 or 1 to 
150,000. It should not be admitted into the general circula- 
tion except in very diluted solutions. 

Infiltration or Terminal Anesthesia. — It has been shown by 
Liebreich that injection of simple water into the tissues in 
sufficient quantity to produce edema induces a transitory 
anesthesia. Infiltration is the preferred method of inducing 
local anesthesia. It results from the pressure of the injected 
fluid upon the nerves and by the direct action of the anes- 
thetic substance upon them. It is called terminal anesthesia 
because the anesthetic acts upon the terminal branches of 
sensory nerves and regional anesthesia because the fluid 
injected affects the nerves of a localized area. To obtain 
anesthesia of a certain area the part should be distended by 
wide infiltration. Schleich found that minute quantities of 
cocaine and morphine in salt solution produced thorough 
and prolonged anesthesia. The solution he used consisted of 
cocaine hydrochlor. (1J gr.), morphine hydrochlor. (gr. J), 
sodii chlor. (3 gr.) and aqua? dest. (2J ounces). The fluid 
should be isotonic with the blood and should contain the 
least amount of the anesthetic agent necessary to render the 
part anesthetic. The addition of a small amount of adrenalin 
to the solution retards the circulation, hence favors analgesia 
and lessens bleeding during the operation. 

Mitchell employs a tablet containing f gr. of cocaine and 
4^ gr. of adrenalin. These tablets are dry sterilized and 
before the operation solutions of two strengths are made by 
dissolving one tablet in a cup of saline solution containing 
50 cc, another by adding a tablet to 100 cc of saline solution. 
The stronger solution is employed for infiltrating the skin 
or blocking nerves and the weaker solution is used for general 
infiltration of the tissues. The total dosage of cocaine by 
infiltration should not exceed 1 or 1J gr. 



ANESTHETICS 215 

The solution is first injected into the skin by a needle 
which is passed in different directions which causes wheals to 
appear. If deeper infiltration is desired the needle is passed 
in the cellular tissues and muscles and they are injected 
with the solution. The operation may be begun after one or 
two minutes, and if during the operation pain is manifested 
additional infiltration should be made. 

Infiltration anesthesia was first employed in minor opera- 
tions, but its use has now been so extended that it is employed 
in many major operations, amputations, appendicitis, goiter, 
gastro-enterostomy, colostomy, typhoid perforation and 
many other operations. This method of anesthesia requires 
patience and skilful manipulation on the part of the surgeon 
and the intelligent cooperation of the patient. 

The injection of the anesthetic agent into the nerve sheath 
or into the nerves supplying the part where the nerves are 
accessible is one of the most satisfactory methods. It is 
known as the 'paraneural or endoneural anesthesia. The 
tissues overlying the nerve are rendered insensitive ' by the 
injection of the solution and the nerve is exposed by dissec- 
tion and the injection is made into the sheath or into the 
substance of the nerve. The result is complete anesthesia 
of the parts supplied by the nerve for twenty-five to thirty 
minutes. This method is frequently employed in operations 
upon the extremities and other parts of the body where the 
administration of a general anesthetic is considered inadvis- 
able. 

In children and nervous subjects it cannot be employed 
with advantage. It also has the disadvantage of causing 
swelling and edema of the tissues at the seat of operation, 
which may interfere with the satisfactory recognition of the 
various anatomical structures. 

Epidural or Sacral Anesthesia. — The nerve trunks which 
form the sciatic and pubic nerves may be anesthetized in 
the spinal canal at the sacrococcygeal junction. The patient 
is placed upon his abdomen, a long needle is inserted and 
passed into the lower opening of the sacral canal and directed 
upward from 1 J to 2 inches. A one-half of 1 per cent solu- 
tion of novocaine is injected. By this injection satisfactory 



216 MINOR SURGERY 

anesthesia generally results for operations upon the bladder 
and rectum. 

Parasacral Anesthesia. — The sacral nerves may be anesthe- 
tized as they emerge from the sacral foramina. The patient 
is placed in the lithotomy position, the tip of the coccyx 
located, a mark made upon the skin If to 2 cm. from the 
midpoint. A needle is passed into the tissues at this point 
and pushed upward in the hollow of the sacrum until it 
strikes the bone. The needle is then withdrawn 1 cm. and 
25 cc of a 0.5 to 1 per cent, novocaine solution is injected as 
the needle is withdrawn to the skin. The needle is then 
introduced at a slightly greater angle to strike the bone 
at a depth of 10 to 12 cm. After withdrawing it 1 cm. 20 
cc of the solution is injected. The needle is withdrawn and 
5 cc of the solution is injected between the coccyx and the 
rectum. The same procedure is repeated on the opposite 
side. For operation upon the uterus and adnexa, lumbar 
paravertebral anesthesia should be added. 

Spinal or Subarachnoid Anesthesia. — Corning, Bier and 
Tuffier found that spinal analgesia may be produced by the in- 
jection of anesthetic substances into the subarachnoid space, 
which extends from the second lumbar vertebra to end of the 
dural sac at the third sacral vertebra. The drugs employed 
are cocaine, eucaine, novocaine, tropocaine and stovaine; an 
isotonic solution of one of these drugs is employed. 

Cocaine and eucaine in 0.05 per cent, solution have been 
employed but seem to be more dangerous than novocaine, 
tropocaine and stovaine so that the latter are generally used. 
Novocaine in a 5 per cent solution or a stovaine solution 
made of stovaine, 4 parts, lactic acid, 2 parts, glucose, 5 parts, 
distilled water enough to make 100 parts or a 5 per cent 
solution of tropocaine which is heavier than the cerebro- 
spinal fluid and sinks before it diffuses, may be used. The 
patient may be given a preliminary injection of morphine 
(-§- gr.) or morphine and atropine (gr. ytw) an h°ur before 
the spinal injection to diminish the psychic shock. 

The technic of the operation is as follows: The entire 
lumbar and sacral regions should carefully be sterilized, and 
the position of the third lumbar interspace — that is, the space 



ANESTHETICS 217 

between the third and fourth lumbar vertebrae — located. 
The patient next sits astride of the operating-table and bends 
forward in the position of ventral flexion, with his elbows 
resting upon his knees, which widens the space between the 
third and fourth lumbar vertebrae, or it may be given with the 
patient on his side with the body bent forward. A few drops 
of novocaine are next injected into the skin over the center 
of this space. A needle between 1 and 2 mm. in circumfer- 
ence, about three times the circumference of the ordinary 
hypodermic needle, and 2| to 3 inches in length, attached to 
a syringe, is next inserted through the skin midway between 
the spinous processes, or a puncture by a tenotome may be 
made through the skin and the needle inserted through this. 
The needle and syringe should be thoroughly sterilized by 
boiling before being used. The needle should be pushed 
forward and a little upwards to cause it to enter the spinal 
canal in the median line, and as soon as resistance disappears 
and fluid appears in the syringe it is evident that the canal 
has been entered. In no case should the analgesic solution 
be injected unless the fluid escapes satisfactorily. After a 
few drops of fluid have escaped the syringe is removed from 
the needle and replaced by one containing the anesthetic 
solution, and 15 to 20 minims of the solution are injected into 
the spinal canal. The needle is then removed and the 
puncture sealed with a small piece of gauze and collodion 
and the patient placed in the recumbent posture. In a few 
minutes anesthesia is usually sufficiently advanced for the 
operation. 

Spinal anesthesia should not be employed in children, nor 
in nervous and excitable patients, but may be employed in 
cases where certain a general anesthetic is contraindicated. 

Following spinal injection, nausea, vomiting, cardiac or 
respiratory failure or headache may occur. Paralytic affec- 
tions of the ocular nerves and spinal paralysis have resulted 
from its use. It fails to furnish satisfactory anesthesia in from 
5 to 10 per cent of the cases. 

Spinal anesthesia is a dangerous method of anesthesia 
which has not increased in popularity, and probably has a 
mortality of 3 to 2000 according to Tuffier. It should be 



218 MINOR SURGERY 

confined to operations below the diaphragm and should not 
be employed as a routine method of anesthesia. 

Jonnesco employed high spinal anesthesia in which the 
injection is made at a level appropriate to the region to be 
operated. This is an even more dangerous method and 
is not to be recommended. The spinal injection of mag- 
nesium sulphate has also been used; 1 cc of a 25 per cent 
solution is employed; it is slow in its action, two or three 
hours often elapsing before analgesia results; recovery of 
sensation after its use is also slow. 

General Anesthesia. — This is characterized by the loss of 
consciousness and abolition of sensation. It may be induced 
for surgical purposes by the inhalation of the vapor of vola- 
tile liquids or gases. As the anesthetic state produced by 
these drugs is one in which positive dangers exist, it should 
be maintained for as short a time as possible. The admin- 
istration of the anesthetic should be in the hands of one who 
has had special training and experience in its use. 

The substances used for general anesthesia are ether, 
chloroform, nitrous oxide gas or combinations of these drugs, 
ethyl chloride or kelene, A. C. E. mixture and scopolamine- 
morphine. 

Preparation of Patient. — Before the administration of a gen- 
eral anesthetic the patient should have a careful examination 
a day or two before operation, if possible, to ascertain the 
condition of the heart, lungs and kidneys. Patients suffering 
from uncompensated valvular disease or myocardial degen- 
eration especially the latter, are not good subjects for 
general anesthesia. The presence of albumin does not con- 
traindicate the use of general anesthetics, but the risk of 
operation is increased. Sugar in the urine increases the risk 
of the anesthetic; diabetic coma may develop. The danger 
is not entirely dependent on the amount of sugar; cases 
showing a small percentage of sugar may develop coma, and 
in others, in which a large amount is present, develop no 
symptoms. The presence of acetone is always dangerous. 
If any of these conditions are present, except in cases of great 
urgency, the operation should be postponed and appropriate 
treatment instituted. 



ANESTHETICS 219 

The bowels should be thoroughly moved the day before 
the operation; this is especially important in operations upon 
the intestines and rectum. The stomach should be empty 
at the time of anesthetization to avoid vomiting, which is a 
troublesome complication. During the twelve hours before 
operation no solid food should be given. If the patient is 
weak a little liquid nourishment may be given four hours 
before. In operations upon emergency cases where the 
stomach is full and vomiting occurs during the use of the 
anesthetic, great care should be taken to keep the fauces free, 
or in such cases the stomach should be washed out before the 
anesthetic is given. It is important that the patient has a 
good night before the operation; this should be secured by 
the use of medicine if necessary. 

The amount of the anesthetic required may be diminished 
by the administration of \ gr. of morphine and atropine sulph. 
yI-q- gr. one-half to one hour before the anesthetic is given. 
This is not indicated in all cases but acts well in nervous and 
timid patients and those who use alcohol to excess. Its use 
is most satisfactory before the administration of nitrous oxide. 
Its use is contraindicated in children, or aged or cachetic 
subjects, or those with obstructive dyspnea from goiter or 
disease of the respiratory tract. The use of morphine in 
properly selected cases insures the patient a quieter anestheti- 
zation and more comfortable period after recovery from the 
anesthetic. Atropine alone may be given if there are exces- 
sive excretions from the fauces and respiratory tract. 

Choice of Anesthetic. — In selecting an anesthetic the surgeon 
should be guided by the results of his examination of the 
patient, its safety and suitability to the individual case. 
Ether is the safest and most easily administered anesthetic, 
and should be selected for the majority of patients. It is a 
cardiac stimulant and increases the blood-pressure, but causes 
irritation of the kidneys and pulmonary mucous membranes. 
Hence, it should not be used in cases having high arterial 
tension, arteriosclerosis, inflammation of the respiratory tract 
or nephritis. 

Chloroform is a cardiac depressant and lowers blood- 
pressure, is stronger than ether and should be administered 



220 MINOR SURGERY 

in smaller amounts with a greater quantity of air and requires 
more skill, experience and watchfulness in its administration. 
In this climate its employment is attended with more danger 
than ether. In hot climates the use of chloroform is attended 
with less danger, but in experienced hands may be used in 
old persons with high blood-pressure and for short operations 
in children. 

The mortality for general anesthetics is, as given by Hewitt, 
as follows: In 400,000 ether administrations, 1 in 16,000 
cases; chloroform, 1 in 3162 cases; ethyl chloride, 1 in 3000 
cases. No deaths from nitrous oxide and oxygen. In Ameri- 
can cases the death-rate of nitrous oxide has been reported 
as 1 in 6905 cases. Nitrous oxide is extensively employed, 
and is generally given by experts which would account for 
the low mortality. Persons suffering from status lymphaticus 
often die suddenly during the administration of general 
anesthetics. 

An anesthetic should never be given to a woman without 
the presence of a third person, as in some cases these agents 
give rise to erotic dreams, and it may be difficult to disabuse 
the patient's mind of the idea that an assault has been com- 
mitted unless the evidence of eye-witnesses at the time of 
the anesthetization can be brought forward to prove that 
such was not the case. 

Administration of a General Anesthetic- — The patient is 
placed upon his back and covered with one or more blankets 
to prevent the surface from being chilled, and the head should 
be turned to one side as in this position mucus is less apt to 
collect in the pharynx and interfere with breathing. The 
anesthetizer should confine his attentions strictly to the 
patient and should have at his side a table on which are 
placed the mask or inhaler, the anesthetic, a hypodermic 
syringe, a basin, tongue forceps, sponge holders, wooden screw 
mouth gag and a hinged mouth gag. He should assure him- 
self that the patient has no foreign body in his mouth, such 
as false teeth, chewing gum or tobacco. He should examine 
the patient's heart and pulse before administering the anes- 
thetic; this enables him to detect any irregular action, and 
at the same time has a good moral effect upon the patient 



ANESTHETICS 221 

if he can assure him that he is in good condition to take the 
au esthetic. A tactful anesthetist can do much to allay the 
fears of the patient. He should watch the patient closely 
during the administration of the anesthetic and should not 
have his attention diverted by the operation. He should 
carefully observe the pulse, respiration and color of the 
patient's face and be prepared to withdraw the anesthetic 
upon the development of any symptom of danger and to treat 
such symptoms should they arise. 

Nitrous Oxide Gas. — This gas, by reason of its great vola- 
tility, produces anesthesia rapidly and the patient recovers 
quickly. It is inhaled through a tight-fitting mask. It pro- 
duces deep cyanosis, due to the exclusion of oxygen from the 
lungs and red-blood corpuscles. It is a very safe anesthetic 
when given by an anesthetizer skilled in its administration. 
It is used in short operations, but a prolonged anesthesia may 
be conducted if it is combined with oxygen. It is at the 
present time not much used in its pure state but is combined 
with oxygen. 

Nitrous oxide causes anesthesia by arresting the oxygena- 
tion of the blood while it is in contact with it, and, in addi- 
tion, the gas produces anesthesia by direct action on the 
cerebral cortex. Nitrous oxide gas is contraindicated in alco- 
holic subjects, or in those having marked atheroma of the 
arteries, as apoplexy may occur, or in any condition of 
obstructed respiration. It should never be administered in 
cases of angina Ludovici, sublingual abscess or enlargement 
of the thymus gland. The apparatus best suited for its 
administration consists of a cylinder of metal in which the 
gas is compressed, which is attached to a rubber bag, which 
has a mouth-piece fastened to it; this is provided with a 
double valve, which prevents the expired air from passing 
back into the bag. The mouth-piece is adjusted over the 
mouth, and after removing any false teeth or foreign bodies 
from the mouth the patient is instructed to take deep, full 
breaths, and in from one-half to one minute the face becomes 
congested and dusky and the breathing becomes stertorous, 
indicating that the patient is fully under the influence of the 
gas. The anesthesia from nitrous oxide cannot be prolonged 



222 MINOR SURGERY 

for more than a few minutes, unless it is given in conjunction 
with oxygen, so that it can only be employed in operations 
which take a short time for their performance, such as the 
extraction of teeth and the opening of abscesses. Unfortu- 
nately, it cannot be used in the reduction of fractures or dis- 
locations, as it does not produce complete muscular relaxa- 
tion. Nitrous oxide is frequently used to produce anesthesia, 
and when this result is accomplished the anesthesia is kept 
up by the administration of ether. 

Nitrous Oxide and Oxygen. — The combination of nitrous 
oxide gas, 92 to 94 per cent, with oxygen, 6 to 8 per cent, is 
the least depressing of any anesthetic and is widely employed 
at the present time for short or prolonged anesthesia. It 
should be administered by a skilled anesthetist. The amount 
of oxygen required is guided by the occurrence of cyanosis 
and stertor; these call for an increase in the oxygen. To 
determine this cyanosis in administering this gas to negroes 
requires great skill. It causes no damage to the blood and is 
followed by the least shock, and recovery from anesthesia is 
very rapid. It may be given to old persons and children, 
but not to infants. It causes a rise in the blood-pressure and 
should not be used in cases of marked arteriosclerosis, emphy- 
sema, valvular disease with dilated heart or regurgitant aortic 
lesions. It does not produce complete muscular relaxation 
and if this is desired the use of a little ether may be required 
to bring about this result. 

The anesthetic state is not produced as rapidly as by 
nitrous oxide gas alone, but it may be prolonged by a skilful 
anesthetizer for hours. It is administered by a special appa- 
ratus, by which the administrator can increase or diminish 
the amount of oxygen, according to the symptoms presented. 
The apparatus now generally employed carries two cylinders 
— one containing nitrous oxide gas, the other oxygen.. These 
are held by a metal standard, to the top of which is attached 
a hollow double yoke supporting the gas bags at its ends and 
a mixing chamber at its center, to which are attached the 
tubing and mouth-piece. Valves are added by which the 
supply of gas and oxygen may be regulated. 



ANESTHETICS 223 

Ether.— Sulphuric ether is one of the most widely employed 
substances in surgery to produce anesthesia; it is probably 
the safest of all anesthetics, except nitrous oxide gas, and for 
this reason should be preferred to all others. Its effects, 
according to Hare, result from the action of the drug — first 
on the brain, then on the sensory tracts of the spinal cord, 
then on the motor tracts, then on the sensory side of the 
medulla oblongata, and finally upon the motor side of the 
medulla, and thereby produces death from respiratory failure 
if given to excess. Its administration is attended with risk 
in the following cases: (1) In infants, in whom it causes 
irritation of the bronchial mucous membrane, with profuse 
secretion of mucus and may cause also bronchopneumonia. 
(2) In aged persons a profuse secretion of mucus and bron- 
chopneumonia may follow its use; it is also contraindicated 
in those subjects in whom there are rigidity of the chest and 
lessened respiratory power. (3) In advanced organic disease 
of the kidneys, and especially in nephritis of the interstitial 
form with urine of a low specific gravity and in diabetic 
subjects. (4) In disease of the heart its administration is 
more dangerous in myocardial than in valvular lesions. (5) 
In cases of obstructed respiration from swelling of the 
pharynx, fixation of the tongue in cancer and cellulitis of the 
neck, and in emphysema and abdominal distention. (6) In 
cases in which examination of the blood shows that the hemo- 
globin is diminished to less than 50 per cent. (7) When the 
bronchial irritation following its use may impair the result 
in operations for hernia and in laparotomy. 

It should also be borne in mind that the vapor of ether is 
very inflammable, and that it is heavier than the air, so that 
lights brought near the patient while being etherized should 
be held at a higher level than the ether can or inhaler. Care 
also should be exercised in employing actual cautery near 
ether vapor. 

The anesthetizer should cover the patient's eye with a 
compress of moist gauze and should be careful that no ether 
comes in contact with the conjunctiva, as severe ether con- 
junctivitis has resulted from this accident. He should also 
be careful in testing the sensibility of the cornea not to 



224 



MINOR SURGERY 



Fig. 173. 



touch it with the finger, but should press upon it through 
the eyelid, for infection of the cornea, resulting in sloughing, 
has resulted from neglect of this precaution. 

Ether produces more irritation of the respiratory tract than 
chloroform and its administration is sometimes followed by 
the development of bronchitis, pulmonary congestion or pneu- 
monia. These complications are less likely to occur if care 
is taken to avoid the administration of ether in patients who 
are suffering from bronchial irritation and to see that a 
patient who has taken ether is not exposed to draughts and 
is not allowed to go out into cold or moist air immediately 
after recovering from the anesthetic. 

Administration of Ether. — 
In the administration of ether 
a towel folded into a cone, a 
pad composed of a number of 
layers of gauze or one of the 
various ether inhalers may be 
employed. The best of these 
is Allis' inhaler, which consists 
of a metallic framework cov- 
ered with leather or a nickel- 
plated case, which carries a 
number of folds of a roller 
bandage, giving a large sur- 
face for the rapid evaporation 
of the drug (Fig. 173). This 
inhaler provides the patient 
with a large amount of atmospheric air; at the same time it 
permits the anesthetizer to administer sufficient quantities 
of ether vapor. 

If a towel folded into a cone is used a few layers of stiff 
paper interposed between the outer layers of the towel 
will keep the cone in shape and prevent the rapid evaporation 
of the ether from its external surface. 

The open or continuous drop method is now very generally 
employed in administering ether. Although it is more waste- 
ful of ether and requires a longer time to produce anesthesia, 
the patient does not receive an excessive quantity of ether 




Allis' ether inhaler. 



ANESTHETICS 225 

vapor, and is less likely to suffer from pulmonary and renal 
irritation and gastric disturbances than when administered 
by the closed method. 

In administering ether by this method a pad of gauze, 
consisting of about twelve layers, is held lightly over the nose 
and mouth of the patient, and ether applied drop by drop, 
the point of saturation of the gauze being constantly changed. 
If the gauze is not too tightly held on the nose and mouth 
sufficient atmospheric air is inhaled with the ether vapor. 

In administering ether the drug is continuously dropped 
upon the gauze or inhaler placed over the nose and mouth of 
the patient. He is then requested to take deep breaths, or 
to blow the ether away, which latter procedure causes him to 
take deep inspirations. In the beginning of etherization the 
patient will resist the inhalation much less vigorously if the 
ether is given slowly with a plentiful admixture of air. The 
first effect of the inhalation of ether is to produce acceleration 
of the pulse and respiration; the mucous membrane of the 
air passages is irritated and coughing often occurs; there is 
also in this stage a disposition to muscular movements, and 
it is frequently necessary to restrain the patient; the brain 
also is excited and the patient is apt to cry out. These 
symptoms call for a continuance of the administration of the 
ether, and not for its withdrawal. Succeeding the stage of 
excitement, if the ether be pushed, profound anesthesia takes 
place, as is evidenced by the loss of consciousness, relaxation 
of the muscular system, moist skin, loss of special senses, 
contracted pupils and slow and deep respiration, tending to 
become stertorous. When the conjunctiva is insensitive to 
the touch of the finger anesthesia is usually profound. When 
the anesthesia is complete the amount of ether inhaled should 
be diminished, and the patient given only so much as will 
keep him well under its influence. It is surprising how small 
a quantity a careful and watchful anesthetizer will require 
to keep the patient fully under its effects for a considerable 
time. The time required to produce anesthesia varies in 
different cases; it is produced in children in a few minutes; 
in adults from ten to twenty minutes are usually required; 
drunkards and those who have taken ether frequently require 
15 



226 MINOR SURGERY 

a larger amount and a longer time to come under its influence. 
After the administration of the drug is stopped the patient 
may continue for some time in an unconscious condition, 
resembling a quiet sleep, or he may awake and exhibit more 
or less symptoms of cerebral excitement. 

First Insensibility from Ether (Ether Rousch). — There often 
exists in the early course of the administration of ether a 
stage of primary anesthesia which lasts for a minute or more, 
and which may be taken advantage of to perform such a 
minor surgical operation as opening an abscess, reduction of 
a dislocation or a fracture, or extraction of a tooth. The 
recovery from this condition is usually very prompt, and is 
not followed by nausea or the after-effects which attend the 
prolonged administration of ether. 

Accidents during Etherization. — During the administration 
of ether, particularly in the early stage, the patient may 
suddenly stop breathing, the face at the same time becoming 
cyanosed. This condition calls for withdrawal of the ether; 
and if an inspiratory effort does not quickly follow, pressure 
should be made upon the front of the chest, and when this 
is relaxed a deep inspiration usually takes place, and no 
further difficulty is experienced. This condition should not 
be confounded with the very common effort of holding the 
breath, the latter occurring with the chest fully expanded, 
the former with the chest empty. 

Vomiting may occur during etherization, and the "vomited 
matter may accumulate in the pharynx or the mouth, and 
obstruct the breathing or may enter the larynx or trachea 
and cause a like result. Vomiting is more apt to take place 
if solid food has been taken shortly before the administration 
of the anesthetic. If this accident occurs and interferes with 
breathing the jaws should be opened and the head turned to 
one side, when the vomited matter will usually escape with- 
out difficulty. If, however, food has entered the larynx, and 
is not ejected by coughing, it will be necessary to perform 
tracheotomy promptly and hold the tracheal, wound open, or 
to introduce a tracheotomy tube and practise artificial respi- 
ration. The breathing may also be obstructed by the accu- 
mulation of mucus and saliva in the pharynx. This is less 



ANESTHETICS 227 

likely to occur if the head is kept to one side during the 
administration of the drug; if it occurs the head should be 
turned to one side, the jaws opened and the material removed 
with small sponges or pieces of gauze fixed to sponge holders. 
The tongue may fall backward and obstruct the breathing 
when muscular relaxation is complete during anesthesia; this 
accident is also less likely to occur if the head is kept to one 
side during etherization. If asphyxia results from falling 
back of the tongue, it should be brought forward by placing 
the fingers on each side beneath the angles of the inferior 
maxillary bone, and pushing the jaw forward, at the same 
time overextending the neck by bending the head backward 

Fig. 174. 




Pushing the jaw forward. 

(Fig. 174), or the mouth should be opened and the tongue 
drawn forward with tongue forceps. Either of these manipu- 
lations is usually sufficient to reestablish the respiratory 
movements. 

If, however, in any of these forms of mechanical asphyxia 
respiratory action is not promptly restored, some form of 
artificial respiration should promptly be resorted to, either 
Laborde's or Silvester's; and of these, Laborde's method, by 
rhythmical traction of the tongue, and Silvester's have 
yielded the most satisfactory results. Sudden arrest of 
cardiac action may call for cardiac massage (p. 236). Efforts 
at resuscitation in these cases should be persevered in for 



228 MINOR SURGERY 

at least half an hour, as apparently hopeless cases have been 
saved by persistent use of these means. 

Failure of respiration may occur also from paralysis of the 
respiratory centers, or spasm of the respiratory muscles; the 
former may occur from an overdose of the anesthetic, or from 
intercurrent asphyxia, syncope or morbid states of the 
respiratory system. 

Spasmodic respiratory failure may occur before complete 
anesthesia, and is liable to arise in muscular and emphysema- 
tous subjects. Respiratory failure from either of these causes 
should promptly be treated by artificial respiration and the 
hypodermic use of strychnine, atropine or digitalis. 

After-effects of Ether. — After complete anesthesia from 
ether, nausea and vomiting are very common, and both are 
more apt to follow in case the patient has taken food shortly 
before the administration of the anesthetic. They may last 
for only a short time or may persist for hours. If persistent, 
the swallowing of a few mouthfuls of hot water will often 
relieve the condition; or the administration of cocaine hydro- 
chlorate (J gr.) with crushed ice, repeated two or three times, 
or the use of crushed ice with champagne or brandy, may be 
followed by satisfactory results. The inhalation of oxygen, 
begun as soon as the ether has been suspended and continued 
for some time is now frequently employed with good results. 
Inhalation of the fumes of vinegar will often prevent nausea 
and vomiting, the vinegar being poured upon a towel or a 
piece of gauze, which is being held over the mouth and nose 
of the patient, and it should be applied as soon as the admin- 
istration of the ether is stopped; it should be used continu- 
ously for some time to be followed by the best results. 

Pharyngeal Insvfflation. — In operations upon the mouth, 
face or larynx the vapor of ether may be administered through 
rubber tubes or catheters, introduced into the pharynx 
through the nostrils. The tubes are lubricated and passed 
through the nares into the pharynx and transfixed with a 
safety pin to prevent them slipping further than is desired. 
These are attached to a vessel containing ether and air, and 
the vapor mixed with air is forced into the tubes by a hand 
bulb or foot-pump bellows. 



ANESTHETICS 229 

Intratracheal lnsvfflation Anesthesia.— In this method of 
anesthesia ether and air are supplied to the lungs through 
a catheter passed through the glottis into the trachea. To 
the free extremity of the catheter is attached a rubber tube, 
connected with the air-pressure apparatus, and air mixed 
with a definite quantity of ether is blown through the tube 
at a pressure of 10 mm. of mercury. After a few minutes 
the pressure is raised to 20 mm. 

The air pressure is maintained by an electric motor or a 
foot bellows. This method of producing anesthesia has been 
advocated by Dr. Elsberg, who has also perfected a portable 
apparatus for supplying the anesthetic mixture at the proper 
pressure. 

The technic is as follows: The patient is first given ether 
in the ordinary manner until well relaxed. The tube, in a 
given case, should fill about one-half of the lumen of the 
trachea. A No. 29 Fr. rubber catheter, which is the size 
required for an ordinary adult (for children an 18 to 22 
catheter is required), is passed through the glottis in the 
trachea with the aid of the Jackson direct laryngoscope, the 
head of the patient being allowed to hang over the edge of 
the table. If one has experience in the introduction of intu- 
bation tubes he can introduce the catheter without the aid 
of the laryngoscope. The catheter should be marked 26 m., 
and not inserted beyond this depth, as this will place the tip 
end of the instrument about 2 inches from the bifurcation of 
the trachea. To prevent the catheter being compressed 
between the teeth, a special bit holding it is placed between 
the jaws. 

The tube from the air-pressure apparatus is next attached 
to the catheter, and the anesthetic mixture of air and ether 
is supplied under the supervision of the anesthetizer. 

By this method it is claimed there are secured: " (1) Even 
and sufficient oxygenation and ventilation of the lungs, with 
no possibility of obstruction of the upper air passages; (2) 
the inhalation of blood mucus (vomitus or foreign bodies 
are prevented by the return current of air around the tube; 
(3) positive pressure may be attained to any desired degree 
if one or both pleural cavities are opened by accident or 



230 MINOR SURGERY 

design — the danger of pneumothorax is thus eliminated; (4) 
in operations upon the head and neck the anesthetist is out 
of the way of the manipulations of the surgeon; (5) there is 
no strain upon the respiratory apparatus and consequent 
strain and harmful effect of the anesthetic upon the cardio- 
vascular and central nervous systems; (6) there seems to be 
less shock; (7) the anesthetic is supplied with a free admixture 
of air, and it is practically impossible to overanesthetize the 
patient. After the operation is completed the ether is cut 
off and pure air is furnished -to the lungs for a few minutes, 
and the patient recovers more promptly from the anesthetic 
state." Experience with this method has demonstrated its 
safety. 

Ether and Nitrous Oxide Gas. — The production of anesthesia 
by the combined use of nitrous oxide gas and ether has been 
quite extensively employed both in England and this country. 
Hewitt considers this method of producing anesthesia far 
superior to any other method which we possess at the present 
time. A special apparatus is required which controls defi- 
nitely the amount of nitrous oxide, ether and air. Anesthesia 
is produced first by the use of nitrous oxide gas, and, as soon 
as this is developed the anesthetic state is maintained by 
substituting the vapor of ether for the nitrous oxide gas. 
No air is given with the gas until anesthesia is complete, 
which should be in from two, to three minutes. Breathing at 
this time is stertorous and cyanosis is well marked. After 
this time air is administered with the ether vapor. Anes- 
thesia by this method is rapidly induced, there is less strug- 
gling and spasm, the quantity of ether employed is smaller 
and the after-effects are less marked, especially vomiting, 
and recovery from the anesthetic state is more rapid than 
when ether is used alone. 

Ether and Oxygen. — The administration of ether with 
oxygen gas has been employed to a considerable extent. In 
the employment of this combination to produce anesthesia 
the patient is first allowed to inhale a small amount of ether 
from an inhaler, and a tube connected with the oxygen 
r eceiver is then introduced into the inhaler and the oxygen 
pis turned on, so that the patient is allowed at the same time 



ANESTHETICS 231 

to inhale the vapor of ether and oxygen gas. A special 
apparatus may also be employed which regulates definitely 
the amount of ether and oxygen furnished. Anesthesia pro- 
duced by this combination is accompanied by less cyanosis, 
vomiting is rare and the patient recovers very promptly from 
the anesthetic state. As the ether vapor and oxygen form a 
highly explosive mixture care should be exercised not to bring 
a flame near the patient during its administration. 

Oil-ether Anesthesia. — Gwathemy, who introduced this 
method of anesthesia, found that when oil and ether were 
introduced into the rectum the heat of the body liberated 
the ether from the oil in the form of gas; this was absorbed 
by the capillaries of the colon and conveyed by the blood to 
the liver, and thence by the greater circulation to the heart 
and lungs. The odor of ether can be detected in the patient's 
breath three or four minutes after the rectal injection. The 
patient should be given 1 ounce of castor oil the evening 
before the operation, and in the morning the bowel should 
be irrigated until the water returns clear. A suppository of 
chloretone, 5 to 10 grs., or an emulsion of the same amount 
of chloretone, should be introduced into the rectum. This 
rectal medication should be followed in a short time by a 
hypodermic of f to i gr. of morphine with t ^-q gr. of atropine. 
This preliminary rectal medication is said to diminish the 
amount of oil-ether mixture required. 

The apparatus required is a clamp, a rectal tube \ inch in 
diameter and 20 inches in length, a glass funnel and a double 
tube for washing out the bowel. The injection, which 
consists of olive oil, 2 ounces, and ether, 6 ounces, should 
be given twenty to thirty minutes before the time of opera- 
tion. The tube should be oiled and passed 4 inches into 
the rectum, and the mixture should be allowed to pass slowly 
into the rectum, a minute being allowed for the introduc- 
tion of each ounce of the mixture. In from ten to thirty 
minutes the patient should be unconscious, respiration 
regular and muscles relaxed. If anesthesia does not result 
after 6 ounces have been given, 2 ounces more may be given; 
more than 8 ounces should not be used. If the breathing 
becomes labored and cyanosis appears the mixture should 



232 MINOR SURGERY 

be withdrawn and the rectum irrigated with warm water 
until the patient's condition is satisfactory. 

If a satisfactory condition of anesthesia does not result a 
small amount of ether may be given by inhalation. After 
the operation the bowel should be irrigated with warm soap 
suds by the use of the double tube, a gallon or more being 
used. Bloody stools, abdominal pain and colitis have not 
followed the use of the oil-ether mixture, and no deaths 
have been reported. 

This method of anesthesia has been sufficiently employed 
to prove that it is safe and usually efficient. It seems to 
act well in cases where fear is a factor, and in obese subjects, 
children and in cases with pulmonary disease. In cases of 
hemorrhoids, fistula-in-ano and colitis it is contraindicated. 
The time required in preparation of the bowel eliminates its 
use in emergency cases. 

Chloroform. — This drug, according to Hare, first affects 
the brain, then the sensory part of the spinal cord, then 
the motor area of the cord, then the sensory parts of the 
medulla oblongata, and finally the motor portions of the 
medulla and produces death from failure of the vasomotor 
center and of the respiratory center unless, as rarely occurs, 
the heart has succumbed to the drug. 

Chloroform is a most dangerous anesthetic, causing death 
by respiratory and cardiac paralysis, which may occur in 
the early stage of its administration, most of the recorded 
deaths have been in healthy middle-aged subjects at the 
beginning of its administration. 

Chloroform is widely used in the British Islands and upon 
the Continent; it is not extensively used in this country 
except in certain districts — as in the southern and south- 
western districts of the United States, and here, as in India, 
its use is followed by fewer fatalities than in the northern 
districts, so that it seems that its use is safer in warm climates. 
The lessened death-rate from chloroform in hot climates is 
accounted for, according to Hare, by the fact that operations 
in the tropics are performed practically in the open air, 
where the patient receives a free supply of fresh air, while 
in colder climates the use of heated operating rooms dimin- 



ANESTHETICS 233 

ishes the supply of fresh air to the patient.. Clinical experi- 
ence has demonstrated that chloroform may be used in aged 
and very young subjects and in puerperal patients with 
comparative safety; deaths from chloroform are more 
common in the middle period of life. It is also to be pre- 
ferred to ether in patients suffering from emphysema of the 
lungs, bronchitis and vascular degeneration of the kidneys. 
It is also employed by some surgeons instead of ether in 
operations upon the mouth when the actual cautery is used 
on account of its less inflammable character. 

Considerable diversity of opinion exists among different 
observers as to whether death resulting from chloroform is 
due to failure of the heart or failure of the respiration, and 
each has brought forward a large amount of evidence to 
prove his views correct. Hare states that chloroform acts 
primarily upon the vasomotor center, secondly upon the 
respiratory center, directly and indirectly, and lastly upon 
the heart. Although it has been demonstrated that chloro- 
form is a direct depressant and paralyzant to the heart 
muscle or its contained ganglia, and that cardiac dilatation 
of various degrees may be brought about by the administra- 
tion of chloroform, yet clinical experience shows that paralysis 
of the respiratory centers is probably the most important 
factor in causing death during chloroform anesthesia, for cir- 
culatory failure in these cases is due to embarrassed or sus- 
pended breathing, and the only method of treatment which 
has been found of value is that which tends to bring about 
respiratory action, namely, some one of the various forms of 
artificial respiration. 

Chloroform is more dangerous in the earlier stages of the 
administration and the gravity of the operation appears to 
have little effect in increasing its danger, as statistics show 
that the greatest number of fatalities have occurred in minor 
surgical procedures, such as extracting teeth, amputation of 
fingers, reduction of dislocations and opening abscesses. 

Preparation of Patient — A patient is prepared for the 
administration of chloroform as in the case of ether (p. 220), 
the same precautions being taken as regards the removal of 
false teeth or foreign bodies from the mouth, and to see that 



234 



MINOR SURGERY 



Fig. 175. 



the clothing about the chest and neck does not restrict the 
circulation or respiratory movements. 

Administration of Chloroform. — Chloroform is administered 
by pouring 1 dram of the drug upon a folded towel, which is 
first held a few inches from the mouth and nose and gradually 
brought nearer, but is not allowed to come in contact with 
the face, as from its local irritating action it will blister the 
surface; the lips and anterior nares should be anointed with 
vaseline. 

Chloroform should not be administered near the flame of 
a gas jet or lamp, as the chloroform vapor is decomposed 
by contact with the flame, producing irri- 
tating fumes composed of hydrochloric 
acid and chlorine, which produces intense 
irritation of the respiratory passages. 

The anesthetizer should remember that 
one of the dangers in the administration 
of chloroform is the risk of too great 
concentration of its vapor, so that he 
should see that a sufficient admixture of 
atmospheric air takes place. 

Chloroform may also be administered 
with Esmarch's inhaler, which consists of 
a wire frame covered with gauze (Fig. 
175). 

Various inhalers have been devised to 
regulate the amount of chloroform admin- 
istered and to secure the proper admix- 
ture of atmospheric air, and the best of 
these probably is Mr. Clover's apparatus. 
Profound chloroform anesthesia is manifested by insensi- 
bility of the conjunctiva to the touch, absence of the reflexes, 
complete muscular relaxation and usually contracted pupils. 
When this stage is reached the inhalation should be stopped, 
and after this time only so much chloroform should be admin- 
istered as is sufficient to keep the patient fully under its 
influence. 

Complete anesthesia should be produced before any opera- 
tion is begun; if undertaken before that time syncope may 




Esmarch's inhaler. 



ANESTHETICS 235 

be produced by reflex inhibition of the heart. If convulsive 
movements take place before the patient is fully anesthetized 
and the face becomes cyanosed the inhalation should be dis- 
continued until these symptoms disappear. The pupils should 
also be watched carefully to see if they respond to light 
or are contracted. If the anesthesia is not complete insen- 
sibility to light or wide dilatation is a sign of danger which 
calls for removal of the anesthetic and active treatment to 
stimulate the circulation and respiration. If the inhalation 
has been stopped and is again in a short time resorted to, 
it should be given very carefully and slowly for syncope may 
suddenly develop from the fact that the heart or the respira- 
tion may feel the effect of the previous use of the drug. 

Accidents During Chloroform Anesthesia. — Mechanical as- 
phyxia may occur during anesthesia produced by chloroform, 
as well as that by ether, by obstruction of the respiratory 
passages by blood, mucus, foreign bodies or the tongue falling 
backward over the epiglottis. These accidents should be 
treated in the same manner as when occurring during ether- 
ization. 

Death during the administration of chloroform may result 
from sudden circulatory failure or from respiratory arrest and 
the dangerous symptoms develop so rapidly that the greatest 
promptness is required to meet them. If the patient presents 
evidences of cardiac weakness before the administration of 
chloroform is begun, he should be given hypodermically y^ 
gr. of atropine, which has proved clinically very active in 
preventing sudden circulatory collapse. The person admin- 
istering chloroform should constantly watch both the pulse 
and the respiration, and should not for a moment have his 
attention diverted from the patient; great vigilance is here, 
if possible, more important than during the administration 
of ether. 

Respiratory Arrest. — During chloroform anesthesia paraly- 
sis of the respiratory centers may occur, giving rise to respi- 
ratory arrest. If this dangerous symptom appears the 
patient's head should be lowered and artificial respiration 
promptly employed to reestablish the respiratory function. 



236 MINOR SURGERY 

Cardiac syncope, developing during the administration of 
chloroform, manifested by pallor, fluttering or arrested pulse 
and cessation of respiration, should be treated by lowering 
the patient's head or inverting the patient and resorting to 
artificial respiration or tracheal insufflation. The use of a 
rapidly interrupted electric current, the hypodermic injection 
of atropine, gr. ^-, or strychnine, gr. y^, hypodermically, 
into the pectoral muscles should also be employed for the 
reason that absorption from a muscle is quicker than from 
the subcutaneous tissues. 

If the heart action is not restored by this treatment cardiac 
massage should be employed, the abdomen should be rapidly 
opened below the costal margin and the hand introduced 
and the heart grasped through the diaphragm and rhythmi- 
cally pressed against the anterior chest wall, making direct 
massage of the heart. Cardiac action has been restored in a 
number of cases by this procedure. The transdiaphragmatic 
method is more rapid and equally as satisfactory as that in 
which the chest is opened. In young children the elasticity 
of the chest wall is so great that pressure upon the heart may 
be made by compressing it between the hands. 

Adrenalin chloride solution in the proportion of 3j of 
1:1000 solution to 1 pint of hot saline solution shall also be 
given intravenously. 

Delayed chloroform poisoning may occur after the patient 
has recovered from the shock of the operation and the use of 
the anesthetic. The symptoms of this accident are vomiting, 
restlessness, active delirium, followed by coma. Jaundice 
and albuminuria soon develop and death results in a few 
days. Diacetic acid and acetone may be present in the urine. 

Chloroform and Oxygen. — The combined use of chloroform 
and oxygen is sometimes employed to produce anesthesia. 
A small amount of chloroform is first administered, and then 
the oxygen gas is introduced into the inhaler, and the two 
gases are inhaled at the same time; or a special apparatus 
may be employed, by means of which a definite amount of 
each drug may be administered* 

C.-E. Mixture. — This consists of 2 parts of chloroform to 
3 parts of ether and is highly recommended by F. W. Hewitt 



ANESTHETICS 237 

for general anesthesia. He considers that in general surgical 
cases it produces better results than any other anesthetic. 
And he considers it especially satisfactory in subjects over 
sixty years of age. Hewitt prefers to administer it by an 
inhaler, but it may be given by the open method. 

The A.-C.-E. Mixture. — This mixture, which consists of 3 
parts of chloroform, 1 part of ether and 1 part of alcohol, has 
been employed by some surgeons in place of ether or chloro- 
form with the idea that the dangers of chloroform are 
diminished by its combination with ether and- alcohol. 
Clinical experience, however, has not proved this view to be 
correct. If administered with as much care as chloroform 
its administration is accompanied with the same safety. 
It should be administered upon a gauze pad or inhaler in 
the same manner as chloroform, and the patient should be 
watched as carefully during its inhalation as during the 
administration of the latter drug, and any complications 
occurring should be treated in the same manner as those 
arising during the use of chloroform. 

Bromide of Ethyl. — This drug was introduced as an anes- 
thetic some years ago, but as a number of deaths followed 
its use, it was abandoned. The time required to produce 
anesthesia is shorter than for ether, but there is often induced 
violent muscular spasm, which renders it an unsuitable 
anesthetic in many cases. 

Bromide of ethyl has again been revived as an anesthetic, 
but clinical experience has proved that its use is not devoid 
of danger, that it is not as safe as ether and that it possesses 
no advantages in point of safety over chloroform. When 
used it should be administered by pouring 1 or 2 drams upon 
an inhaler or a towel, and the patient should be watched 
with the same care as during the administration of chloroform. 

Chloride of Ethyl or Kelene. — This drug has been employed 
by inhalation to produce general anesthesia. It is prin- 
cipally used to produce anesthesia for short operations, or 
may be used to bring about anesthesia which is afterward 
continued by the use of ether. The advantages of its use 
are that anesthesia can be produced in a few minutes and 
that recovery is rapid and unaccompanied by nausea or 



238 MINOR SURGERY 

other unpleasant symptoms. It is administered in the same 
manner as ether, the spray being directed into a cone or 
inhaler. 

Scopolamine (Morphine Anesthesia) .—This drug, an alka- 
loid closely resembling hyoscine, has Been extensively used 
in recent years. It is often given to produce rapid anesthesia 
and the anesthetic state is continued by the administration 
of ether. It has not proved as safe an anesthetic as ether 
as a number of deaths have been reported from its use. It 
is usually employed in combination with morphine, either 
in repeated doses without any other anesthetic or in a single 
dose preliminary to inhalation anesthesia, ether or chloroform 
being employed. In the former method the usual procedure 
is to give three hypodermic injections of scopolamine hydro- 
bromate, gr. -j-g-g- (0.0004 gm.), and morphine, gr. f (0.008 
gm.), at intervals of a half hour to an hour before the opera- 
tion. The solution of scopolamine should be freshly made, 
as it decomposes rapidly if kept for more than a few days. 
If the drug acts well the patient becomes sleepy after the 
first injection, is fast asleep after the second and unconscious 
and insensible to pain after the third. The third injection 
is not usually felt by the patient. After the operation is 
finished the patient is returned to bed unconscious and con- 
tinues to sleep for five hours after the last injection. 

In the latter method a hypodermic injection of scopola- 
mine hydrobromate, gr. t ^q- (0.00065 gm.), and morphine, 
gr. \ to i (0.01 to 0.016 gm.), is given about half an hour 
before general anesthesia is begun. The advocates of each 
method report very favorable results. It is probable that 
the second is, on the whole, the safer and more satisfactory. 
Scopolamine morphine alone often fails to cause satisfactory 
anesthesia in a large number of cases. It is a most dangerous 
method of anesthesia and has been responsible for a large 
number of deaths. H. C. Wood estimates the mortality at 
4 to 1000. It certainly reduces the amount of ether or 
other anesthetic employed, and almost entirely abolishes the 
disagreeable after-effects. It should not be used in persons 
under sixteen years of age or in those over sixty, in cases of 
heart disease or persons with a tendency to pulmonary edema. 



ANESTHETICS 239 

After-effects of Anesthetics. — Nausea is not common after 
chloroform anesthesia. The treatment of this condition 
following etherization has been previously described. The 
temperature is usually notably lowered by anesthetics, so 
that it is always well to apply artificial heat and keep the 
patient well covered. A form of mental disturbance known 
as confusional insanity is often attributed to the use of 
anesthetics, but as it does not usually develop until some 
time, often two or three weeks, after their employment, 
H. C. Wood was of the opinion that the relation between the 
mental symptoms and the anesthetic has not been clearly 
proved in these cases, and that it is rather the outcome of a 
peculiar depression of the cerebral cortex produced by the 
shock of the operation itself, or by the emotional strain 
due to the surgical illness. This view seems to be confirmed 
by the fact that many of the cases of emotional insanity 
which are observed follow injuries in which no anesthetic 
has been given. Albuminuria and glycosuria may follow the 
administration of ether or chloroform, but are usually only 
temporary conditions. 

Patients who have been subjected to prolonged anesthesia 
should be carefully watched by a nurse or trained attendant 
until consciousness returns; it is well to have such patients 
turned from one side to the other at intervals to favor free 
pulmonary expansion. If there is any cyanosis due to the 
accumulation of mucus or blood in the fauces this should be 
removed and oxygen should be inhaled. 

Postanesthetic Paralysis. — This may arise during anesthesia 
as the result of cerebral hemorrhage or embolism. It usually 
involves arms or legs and results from the nerves supplying 
these parts being subjected to prolonged pressure. 

Paralysis of the nerves of the brachial plexus may follow 
prolonged anesthesia when the arm is drawn high above the 
head ; it is not due to the anesthetic, but results from stretch- 
ing of the nerves over the head of the humerus or their com- 
pression between the clavicle and the first rib. Paralysis of 
the musculospiral nerve may also occur from prolonged 
pressure of the arm upon the edge of the table. Pressure 
exerted in the flexure of the knees by the edge of the table, 



240 MINOR SURGERY 

while in the Trendelenburg position, may result in paralysis 
of one or both internal popliteal nerves. Recovery usually 
follows in this variety of paralysis. 

Acidosis, Acid-intoxication. — This condition arises from 
the accumulation of acids in the blood, the urine containing 
diacetic acid and acetone, and results from a lack of, or failure 
of assimilation of carbohydrates. It frequently develops in 
diabetes, and sometimes follows operation in which a general 
anesthetic has been given. It is said to be more frequent 
after chloroform anesthesia than after ether. 

Symptoms. — These occur after the patient has regained 
consciousness. Persistent vomiting of watery fluid, restless- 
ness, delirium, normal temperature, rapid pulse and the 
odor of acetone may be detected on the breath. Mild cases 
recover in a few days under alkaline treatment, but in severe 
cases a fatal issue may occur in from one to iive days. 

Persistent vomiting after operation demands prompt 
examination of the urine. 

Treatment. — This consists in the use of alkalis, sodium 
bicarbonate, 10 to 20 grains, every two hours. If not retained 
it may be given by enteroclysis or intravenously. The 
latter method is not free from danger. In severe cases 
where othere means fail, Lindeman advises transfusion of 
blood from a donor whose blood has been rendered alkaline 
by taking large doses of bicarbonate of soda. 

Hypnotism. — The anesthetic state of hypnotism has been 
utilized for the performance of surgical operations. Schmeltz 
and others have recorded operations done under this influ- 
ence, the patient apparently suffering no pain. While there 
is no doubt that the anesthetic state can be obtained by 
hypnotism, which might be serviceable in surgical operations, 
yet we do not believe that it will be of general utility. 



TRUSSES. 

A truss for the palliative treatment of hernia is a mechani- 
cal contrivance with one or more pads and a strap: These 
are held in position by a spring to which they are attached, 



TRUSSES 241 

which holds the pad in contact with the skin over the hernial 
opening. 

Trusses should only be recommended in infants and patients 
who, from their age or physical condition, are not good sub- 
jects for anesthesia or operation. Local anesthesia has placed 
some of these subjects in the operative class. The cure of a 
hernia in children sometimes results from the wearing of a 
proper truss, but rarely in adults. The only cure for hernia 
is operation, which should always be recommended in suitable 
cases. The possibility of strangulation and the limitations 
in exercise, which the wearing of a truss entails, often induces 
even timid patients to select the operative treatment of hernia. 

Trusses are usually applied in cases of reducible and some- 
times in irreducible hernia?, and are used in the treatment 
of hernia? at all ages; in infants and young children the con- 
tinued use of a properly fitting truss is often followed by a 
radical cure of the hernia. They are made with steel or 
rubber springs and with pads of wood, rubber, celluloid or 
horsehair, covered with chamois skin; their shape and the 
pressure which they should exert vary with the variety of 
hernia for which they are applied. 

A firm compress applied over the inguinal canal or crural 
ring, secured in position by a firmly applied spica-of-the- 
groin bandage, forms a very satisfactory temporary means 
of preventing the descent of a hernia. 

A properly fitting truss should be worn without discom- 
fort to the patient — that is, should not make too much 
pressure upon the skin at the points where the pads are 
applied, and should absolutely prevent the descent of the 
hernia. In testing the adequacy of a truss after application, 
to prevent the escape of the hernia, the patient should be 
instructed to separate his legs, bend forward over the back 
of a chair and cough or strain forcibly; if this does not bring 
the hernia down, control of the rupture may be considered 
satisfactory. 

Trusses should be applied after the complete reduction of 

the hernia, while the patient is in the recumbent posture. 

When first applied the truss should be worn both during the 

night and day; and if the skin becomes tender at the points 

16 



242 



MINOR SURGERY 



Fig. 176. 



of pressure it should be sponged with alcohol and alum, 
then dried and dusted with powdered starch or lycopodium. 
Patients at first sometimes complain of discomfort in wearing 
a truss, but they soon become accustomed to its presence. 
After a truss has been worn for some time its use at night, 
while the patient is in bed, may be dispensed with, but the 
patient should not remove it until he is in bed in the recum- 
bent posture, and he should reapply it before he rises in the 
morning. In children it is better to have the truss worn 

continuously; and if it is re- 
moved for bathing the nurse 
should be instructed to place 
her finger over the ring to pre- 
vent descent of the hernia until 
the truss is applied. In apply- 
ing trusses to male children 
care should be taken not to 
make pressure upon an unde- 
scended testicle. 

Worsted Truss. — This appliance 
may be used in the treatment 
of inguinal hernia in infants, 
and is made from an ordinary 
skein of worsted, one part of 
which is made to pass around 
the body just above the iliac 
crests, the other joins this in 
front and behind, forming a 
perineal band. The knot made 
by the two bands in front should be directly over the ingui- 
nal ring (Fig. 176). 

Trusses for Inguinal Hernia. — In measuring a patient for 
this form of truss the circumference of the body midway 
between the crest of the ilium and the great trochanter should 
be taken, and the distance from the symphysis pubis to the 
anterior-superior spinous process of the ilium may also be 
given, as half of this distance corresponds to the position of 
the internal abdominal ring. In reducible inguinal hernia 
the truss pressure should be exerted upon the inguinal canal 




Worsted truss. 



TRUSSES 



243 



and directly backward. To control this variety of hernia a 
single-spring truss (Fig. 177) may be employed, or the use 
of a truss having a double spring with flat pads on each side 
of the spine attached to the springs and a smaller pad over 
the inguinal canal on the unaffected side, with a full pad on 
the side of the hernia, will often be efficient. This, which 



Fig. 177. 



Fig. 178. 




Truss for inguinal hernia. 



Hood's truss. 



is known as Hood's truss, is one which will be found a very 
satisfactory instrument, both in inguinal and femoral hernia 
(Fig. 178). 

Trusses for Femoral Hernia.— In measuring a patient for 
this variety of truss, the circumference of the body midway 
between the crest of the ilium and the great trochanter should 
be taken; the distance of the saphenous opening from the 
symphysis pubis, as well as from the anterior iliac spine, 
should also be taken. In reducible femoral hernia the truss 



Fig. 179. 



Fig. 180. 




Hood's truss for femoral hernia. 



Truss for umbilical hernia. 



pressure should be directed backward against the femoral 
canal, and the pad should be large enough to make pressure 
upon the adjacent tissues through which the hernia passes, 
as well as upon the relaxed tissue covering the femoral canal. 
As in inguinal hernia, either a single or a double spring truss 
may be employed (Fig. 179). 



244 MINOR SURGERY 

In applying a truss for femoral hernia, care should be taken 
to see that the pad does not rest upon the pubes, and thus 
remove the pressure from the crural ring and adjacent tissues 
and prevent the proper control of the hernia. 

Trusses for Umbilical Hernia. — In measuring a patient for 
this variety of truss, the circumference of the body over the 
umbilicus should be taken. In reducible umbilical hernia 
the truss pressure should be directed backward and the pad 
should bear rather on the tendinous margins of the ring than 
on the hernial opening. A truss for this variety of hernia 
should have a flat or slightly convex pad, which is held in 
position over the umbilical ring by means of springs having 
counter pads on either side of the spine attached to their 
extremities; these are fastened together by a strap (Fig. 180). 

A simple and satisfactory truss for umbilical hernia in 
infants consists of a penny covered by adhesive plaster, or a 
small flat compress of linen, held over the umbilical ring by 
one or two strips of adhesive or rubber plaster about 2 inches 
in width, or by a broad strip of perforated rubber adhesive 
plaster, which should be applied so as to cover in about the 
anterior two-thirds of the circumference of the body. A 
penny, or a small flat compress of linen, will be found much 
more satisfactory than the conical rubber or cork pad often 
recommended. 

Trusses for Irreducible Hernia. — The application of a truss 
to this variety of hernia protects it from injury and prevents 
its further protrusion. Such trusses are secured in the same 
way as those for reducible hernia, but the pads are made 
concave or cup-shaped, or may have an air cushion or water 
cushion attached to the pad. 

CATHETERS AND BOUGIES. 

Catheters are hollow tubes, made either of metal, India 
rubber or other flexible substances. 

Sterilization of Catheters and Bougies. — To avoid infection 
of the urethra and bladder it is important that catheters and 
bougies should be sterilized thoroughly before being intro- 
duced (p. 429). 



CATHETERS AND BOUGIES 245 

Infection of the bladder may occur from matter contained 
in the urethra so that this canal should also be sterilized. 
If it is possible the patient should pass the urine to wash 
out the urethra, and a solution of boric acid should be 
injected before the instrument is passed. Before passing 
catheter or bougies the meatus, glans penis and vulva 
should be washed with green soap followed by sterile water 
and 1 : 4000 bichloride solution. 

To lubricate the instrument sterilized liquid vaseline, olive 
oil, lubrichondrin or (K-Y) should be employed. 

Metallic Catheters. — These are made of silver or, if con- 
structed of other metals, they should be plated with silver 
or nickel, to give them a smooth, bright surface which can 
easily be kept perfectly clean; and their shape should con- 

Fig. 181. 



1, soft rubber catheter; 2, metal catheter. (Ashhurst.) 

form to that of the normal urethra (Fig. 183). The shape 
of the metallic catheter is sometimes changed to meet certain 
indications ; for instance, for use in cases of enlarged prostate 
it is longer and has a larger curve than the ordinary instru- 
ment (Fig. 183). The metallic female catheter is shorter and 
has a much smaller curve than the instrument used for the 
male urethra. A female catheter made of glass is now 
frequently employed, and has the advantage of easy steriliza- 
tion. 

Flexible Catheters. — The most commonly used variety of 
flexible catheter is that known as the English catheter, which 
is made of linen and shellac, and is provided with a stylet; 
it can be moulded into any shape desired by dipping it into 
hot water, which renders it flexible and, after moulding it to 



246 



MINOR SURGERY 



the proper curve, this can be fixed by immersing it in cold 
water, which hardens it again. 

The French flexible catheter is made of India rubber, or a 
combination of this material with other substances. These 
instruments are conical toward their extremities and termi- 
nate in an olive-shaped point; they are provided with one or 
two smoothly finished eyes near the vesical extremity (Fig. 
182). 

Fig. 182. 




French flexible catheter. 

Another form of flexible catheter, known as the elbowed 
catheter, or Mercier's catheter (Fig. 183), has an angle or 
elbow near its vesical extremity or, at times, two elbows, 
(Fig. 183); these are often found satisfactory instruments to 
use in cases of enlarged prostate. A variety of flexible 
catheters made of soft India rubber is also sometimes em- 
ployed. 

Fig. 183. 




Prostatic catheters: 1, Mercier's coude (elbowed) catheter; 2, Bi-coude, or double 
elbowed catheter; 3, English catheter mounted on an overcurved stylet — when the 
stylet is partly withdrawn the catheter assumes the form indicated by the dotted lines; 
4, metal catheter with prostatic curve. (Ashhurst.) 

Catheters and bougies are made according to a certain 
scale. The English scale runs from No. 1 to No. 12; the 
American, from No. 1 to No. 20; and the French, from No. 
1 to No. 40. 



CATHETERS AND BOUGIES 



247 



Bougies and Sounds. — Bougies. — These are flexible instru- 
ments which correspond in size and shape to the English 



Fig. 184. 




Passing a sound from the patient's right side. Observe how the sound is held in the 
fingers, and note that no force can be used. (Ashhurst.) 

Fig. 185. 




Fig. 185. — The urethral sound fully introduced. Note the angle it makes with the 

horizon. (Ashhurst.) 



and French catheters; and besides there are the acorn-pointed 
bougie (Fig. 186) and the filiform bougie, which latter is made 
of whalebone or of the same material as the ordinary French 



248 



MINOR SURGERY 



bougie and catheter. These instruments are of very small 
diameter and may often be passed through strictures which 
will admit no other form of instrument (Fig. 186). 

Sounds. — These are solid instruments, usually of steel, with 
a smooth surface and plated with nickel; they correspond in 
size and have the same curve as the metallic catheter; the 
handle is flattened to allow the operator to grasp them firmly; 
they are employed in the treatment of strictures by dilata- 
tion (Fig. 186) ; they should be sterilized and passed in the 
same manner as metallic catheters (Fig. 186). The sound 



Fig. 186. 




m 



Urethral sounds and bougies: 1, steel sound; 2, bulbed sound; 3, bougie a boule; 
4, olive tipped bougie, made of webbing, with a leaden core; 5, 6, 7, filiform bougies 
made of whalebone. (Ashhurst.) 



used in dilating strictures of the meatus is straight, and is 
shorter than the sound employed in the treatment of urethral 
strictures A metallic sound with a shorter curve than the 
ordinary sound is used for exploration of the bladder for 
calculus or tumor. 

Introduction of a Catheter. — For the introduction of a 
catheter the patient may be in the standing, sitting or recum- 
bent posture — the latter is the best in most cases; he should 
rest squarely on his back and have the thighs a little flexed 
and separated. 

Before passing a metallic catheter the surgeon should see 



CATHETERS AND BOUGIES 



249 



that it has been sterilized, and after warming and oiling it he 
stands upon the left side of the patient and grasps the penis 
with the left hand, and turns it over the pubis and introduces 
the beak of the catheter into the meatus and gently passes 
it along the urethra until its point passes beneath the sym- 
physis pubis; at this point the handle is elevated and gently 
depressed between the thighs, when the beak will pass into 
the bladder (Fig. 187). 

In passing a catheter in case of enlarged prostate, when the 
prostatic region is reached, difficulty is sometimes experienced 
in the further passage of the instrument; this may be over- 
come by introducing the finger into the rectum and guiding 
the catheter through the prostatic urethra; or if the prostate 

Fig. 187. 




&- 





Method of introducing a metal catheter. (Ashhurst.) 



is found much enlarged the catheter should be withdrawn and 
a prostatic catheter (Fig. 183) substituted. The same 
manipulation is practised as in passing metallic sounds. 

Flexible catheters and bougies are passed by grasping the 
penis and holding it in such a position that it is at a right 
angle to the axis of the body, and the catheter or bougie 
is introduced into the meatus and conducted through the 
urethra into the bladder by gently pushing the instrument 
downward. In this variety of instrument, which has no 
curve, the surgeon has no means of guiding the point of the 
instrument, and if an obstruction is met, he should withdraw 
the instrument slightly and make another attempt; all 
manipulations should be extremely gentle. 



250 MINOR SURGERY 

Passing the Female Catheter. — It was formerly considered 
important to pass the female catheter without exposing the 
patient. At the present time it is rarely done, as it is con- 
sidered more important to sterilize the vulva and region of 
the orifice of the urethra to avoid infection of the bladder. 
After washing the vulva with soap and water, and irrigating 
it with boric solution or normal salt solution, the orifice of 
the urethra is exposed, by separating the nymphse, and the 
catheter is introduced into the bladder. 

Tying the Male Catheter in the Bladder. — When it is desir- 
able to retain a catheter for some time in the male bladder, 
it is necessary to secure it to prevent its slipping out. Either 
a metallic or flexible catheter may be employed; but, as a 
rule, the flexible instrument is the most comfortable to the 

patient, and is to be preferred. 
FlG - 188 - There are several methods of se- 

curing it in the bladder. 

By one method, two narrow 
strips of tape or two or three 
strong silk ligatures are attached 
to the rings at the end of a 
metallic catheter, or are securely 
fastened around the end of the 
Tying in catheter. flexible instrument; these are next 

brought backward, one on each 
side of the penis, and the skin is drawn forward and a strip 
of adhesive plaster \ inch in width is passed over the strings 
or tapes and carried three or four times around the body 
of the penis just behind the glans. If the skin has been 
brought well forward before the strips have been applied 
the ligatures are tightened as it slips back and the catheter 
has not too much play (Fig. 188). 

Another method consists in fastening a strong silk ligature 
around the catheter just in advance of the meatus; the two 
ends are next brought backward and tied in a knot behind 
the corona glandis; the ends are then carried around the 
penis behind the corona and tied on one side of the frsenum; 
the foreskin is slipped forward and covers the ligatures. 
A catheter may also be secured in the bladder by tying the 




CATHETERS AND BOUGIES 



251 



Fig. 189. 



ends of the silk ligatures which are attached to the instrument 
in advance of the meatus to tufts of pubic hair. 

Another method of securing the catheter is to perforate 
the free end with a needle armed with a double ligature of 
silk or hemp; the needle being removed, two loops are made 
of the proper length, and these are passed through the ends 
of a T-bandage, which is secured around the waist, the tails 
being brought up on either side of the scrotum and secured 
to the body of the bandage passing around the waist. 

In the female, when it is desirable to keep the bladder 
empty, the self-retaining catheter is usually employed, which 
consists of a catheter with a bulb at its 
vesical extremity, or an ordinary catheter 
with silk loops, and a T-bandage may 
be employed in the same manner as in 
securing a male catheter. 

Irrigation of the Bladder. — This proce- 
dure may be required in the treatment of 
cystitis or in sterilizing the bladder, and 
is accomplished by passing a flexible 
catheter with a large eye into the blad- 
der, or a double or two-way catheter may 
be employed. A syringe, or, better, a 
rubber bulb holding about a pint, hav- 
ing a nozzle and stop-cock (Fig. 189) is 
filled with warm water, or with any medi- 
cated solution which is desired, and it is 
then attached to the free end of the cathe- 
ter and the contents are gently injected into the bladder; care 
should be taken that the bladder is not too much distended. 
A small metallic or glass funnel with a rubber tube attached, 
which is connected with the catheter in the bladder may also 
be used to irrigate the bladder. A glass or metal receptacle 
with a tube and shut-off clamp is attached to a stand about 
2 feet above the bed; this may also be used in irrigation of 
the bladder. When the desired amount of fluid has been 
injected it is allowed to run out of the catheter, and the 
procedure may be repeated until the solution comes away 
perfectly clear. 




Rubber bag with stop- 
cock for irrigation of the 
bladder. 



252 



MINOR SURGERY 



Fig. 190. 



The bladder may also be irrigated without using a catheter, 
the resistance of the compressor muscle of the urethra being 
overcome by the pressure of a column of water. The patient 
sits in a chair and a rubber or glass nozzle with a large bul- 
bous tip, which closely fits the meatus, is inserted into it; 
the nozzle is connected by a rubber tube with a reservoir con- 
taining the fluid for irrigation. The reservoir is raised to a 
height of 3 to 6 feet above the patient. He is directed to 
take deep inspirations, and soon the bladder becomes filled 
with water, when the nozzle is removed, and the patient 
empties the bladder naturally. In some 
cases a little time is required before the 
column of water overcomes the resistance 
of the compressor muscle, or its entrance into 
the bladder may be hastened by directing 
the patient to attempt to urinate. 

Care should be taken to see that the 
bladder is perfectly emptied of the solution, 
and in cases of paralysis of the viscus gentle 
pressure should be made upon the abdomen 
over the pubis to accomplish this object. 
Solutions of boric acid and permanganate of 
potassium, and weak solutions of carbolic 
acid and of nitrate of silver or argyrol are 
often employed in washing out the bladder 
in cystitis. 

Urethral Injections. — In the treatment of 
urethral inflammations the injection of medi- 
cated solutions is generally made use of; and as these injec- 
tions are usually made by the patient himself, he should be 
shown or instructed how to employ them. A rubber syringe 
having a conical nozzle, and holding about 2 or 3 drams, is 
the best instrument to employ for this purpose (Fig. 190). 
The syringe having been filled with the solution, the patient 
sits upon the edge of a hard chair, with the thighs separated, 
grasps the syringe between the thumb and middle finger of 
the right hand, the tip of the index finger resting upon the 
end of the piston, and inserts its conical end from f to J inch 
within the meatus, which is held open by the thumb and 




Shape of nozzle of 
urethral syringe. 



SUTURES 253 

finger of the left hand. After the introduction of the nozzle 
of the syringe the tissues should be pressed tightly around it, 
the pressure being made laterally, so as to narrow the 
urethral opening instead of broadening it, as is the case 
when compression is made in an antero-posterior direction. 
After the fluid has been thrown into the urethra in this 
manner the syringe is removed, and the patient is instructed 
to hold the lips of the meatus together for one or two minutes, 
to prevent escape of the fluid. 

Urethral irrigation may also be practised by means of grav- 
ity, a short rubber or glass tube, or a glass urethral nozzle 
being connected by a rubber tube with a reservoir containing 
the fluid to be used, the reservoir being placed slightly above 
the patient. 

SUTURES. 

A variety of materials are employed for sutures, such as 
silk, catgut, linen, celluloid thread (Pagenstecher's suture), 
silver wire, silkworm gut, kangaroo tendon, horsehair and 
equisetene. The materials most frequently employed at the 
present time are either catgut, silk or silkworm gut, although 
some surgeons prefer silver wire. Catgut and kangaroo ten- 
don are practically the only substances employed which are 
absorbable; the other varieties of suture require removal 
after their application, although some sutures, such as the 
silk, if absolutely sterile, when buried in wounds may be cut 
short, as they are apt to become encysted and remain indefi- 
nitely in the tissues. It matters little what variety of material 
be employed for suturing if the surgeon is careful to see that 
it is rendered thoroughly aseptic before being brought in 
contact with the wound. 

Sutures of Relaxation. — These sutures are entered and 
brought out at some distance from the edges of the wound, 
and are employed to prevent dangerous tension upon the 
sutures which approximate the edges of the skin. This form 
of suture is employed in the quilled, button or plate suture. 

Sutures of Coaptation. — These are superficial sutures applied 
closely together, and include only the skin; they are employed 



254 MINOR SURGERY 

to secure accurate apposition of the cutaneous surface of 
wounds. 

Sutures of Approximation. — These sutures are applied deeply 
into the tissue to secure approximation of the deep portions of 
a wound ; this object is accomplished by the use of the quilled, 
buried, button or plate suture. 

Secondary Sutures. — These sutures are applied when the 
surfaces of the wounds are covered by granulations, when the 
primary sutures have failed to secure apposition of the edges 
of the wound, in cases of secondary hemorrhage where the 
opening of the wound has been necessitated to turn out the 
blood clot and secure the bleeding vessel, and in plastic 
operations where the primary sutures have failed to secure 
adhesions of the edges of the flaps. They are also employed 
with advantage in closing wounds in cases in which it was 
necessary to pack the wound with antiseptic gauze, or to 
allow hemostatic forceps to remain clamped upon bleeding 
tissues in the wound at the time of operation. The sutures 
should in such a case be introduced and loosely tied at this 
time, and when the packing or forceps is removed at the end 
of two or three days the sutures are tightened so as to secure 
apposition of the edges of the wound. Wounds treated by 
the Carrel-Dakin method as soon as they have become sterile 
are closed by secondary sutures. 

Surgical Needles. — Needles for surgical use are of different 
sizes and shapes (Fig. 191); straight needles are the ones 
commonly employed, but curved needles will be found most 
convenient for the introduction of sutures in wounds in 
certain locations. Hagedorn needles, which are flat and have 
sharp cutting edges, make a narrow linear wound in the tissue, 
and are useful in some cases. For the introduction of sutures 
in the intestines or hollow viscera, the ordinary sewing needle 
is generally employed, as it does not cut the tissues, but 
merely separates them, and its puncture is not likely to bleed. 
Tubular needles are often employed in introducing sutures in 
wounds in which the use of an ordinary needle is difficult. 
For instance, in the operation for cleft palate, and for the 
introduction of sutures in deep wounds, a mounted needle 
will often be found very useful (Fig. 192) . Reverdin's needle, 



SUTURES 



255 



which consists of a handled needle with an eye which is closed 
with a slide, is useful in passing deep sutures. The needle is 
first passed through the tissues, then threaded and withdrawn 
carrying the suture with it. Needles should be sharp and 
clean, and should be rendered thoroughly aseptic before being 
used. Needles should 

be sterilized by boil- Fig^iqi. 

ing, and may be pre- 
served in a saturated 
solution of carbonate 
of sodium or albolene 
to prevent rusting. A 
needle holder is often 
required for the satis- 
factory introduction 
of sutures in wounds 
in certain localities 

(Fig. 193) ; if this is not at hand the needle may be held by a 
pair of hemostatic forceps. 

Method of Securing Sutures and Ligatures. — Metallic sutures 
are usually secured by twisting the ends together or by pass- 
ing the ends through a perforated shot and clamping the shot 
with a shot-compressor, which securely fixes them. 




<?TT*= 



Surgical needles. 




1, Reverdin's needle, showing at a eye opened, at b eye closed; 2, ordinary mounted 

needle. (Ashhurst.) 

Sutures and ligatures of catgut, silk, silkworm gut, kangaroo 
tendon or horsehair are secured by tying, and several different 
knots are employed to secure them. 

Reef or Flat Knot. — This is one of the best forms of knot to 
use in securing sutures or ligatures, and it is made by passing 



256 



MINOR SURGERY 



one end of the thread over and around the other end, and the 
knot thus formed tightened ; the ends of the thread are next 
carried toward each other and the same end is again carried 
over and around the other, and when the loop is drawn tight 
we have formed the reef or flat knot (Fig. 194). 



Fig. 193. 




A convenient form of needle holder. (Ashhurst.) 

Surgeon's Knot. — This knot is formed by carrying one end 
of the thread twice around the other end (Fig. 195), and after 
tightening this loop the same is carried over and around the 
other end as in the case of the final knot of the reef or flat 



Fig. 194. 



Fig. 195. 




Reef or flat knot. 



Surgeon's knot. 



knot. The surgeon's knot and reef knot combined is one of 
the best methods of securing sutures or ligatures of catgut or 
silk, as the first knot is not apt to relax before the second knot 
is applied (Fig. 196). 



SUTURES 



257 



Granny Knot. — This method of tying the ligature or suture 
should not be employed, as the resulting knot is not as secure 
as the reef knot and is apt to relax : it differs from the latter 
in the fact that one end of the thread having been carried 
across and around the other end, the knot is completed by 
carrying the same end 

under and around the FlG - 196 - 

other end of the thread 
(Fig. 197). 

Staffordshire Knot. — 
This is much used to 
secure the pedicle in the 
removal of abdominal 
tumors, and is applied as 
follows : A handled needle 

armed with a stout silk ligature is passed through the pedi- 
cle, and then withdrawn so as to leave a loop on the distal 
side; this loop is drawn over the tumor, and one of the 
free ends is passed through it so that one end is above 
while the other end is below the retracted loop (Fig. 198). 
The ends are then seized and drawn through the pedicle; at 




Surgeon's knot and reef knot combined. 



Fig. 197. 



Fig. 198. 





Granny knot. 



Staffordshire knot. 



the same time the thumb and forefinger are pressed against 
it until sufficient constriction is made, and the ends are finally 
secured by tying as in the securing of an ordinary ligature. 

Varieties of Sutures. — The Interrupted Suture. — This 
suture, which is the one most usually employed in the 
apposition of wounds, consists of a number of single stitches, 
17 



258 



MINOR SURGERY 



Fig. 199. 



each of which is entirely independent of those on either side. 
In applying this suture the surgeon holds the edge of the 
wound with the fingers or forceps and thrusts the needle, 
previously threaded, through the skin three or four lines from 
the edge of the wound. He then passes the needle from 
within outward through the tissues of the opposite flap at the 
same distance from the edge of the wound (Fig. 199). Each 
stitch is secured as soon as it is passed— by tying if a silk, 
catgut, or silkworm-gut suture be used, or by twisting if a 
silver-wire suture is employed. 

A suture may be used with a needle 
threaded on each end, in which case both 
needles are passed from within outward. 
The sutures may be secured as soon as ap- 
plied, or they may be left unsecured until 
a sufficient number have been introduced, 
and then they may be secured by tying 
or twisting. Care should be taken to see 
that they make no tension on the edges of 
the wound, and that they are so intro- 
duced as to make the best possible apposi- 
tion of the parts. 

Buried Sutures. — In extensive and deep 
wounds it may be found necessary to intro- 
duce both buried and superficial sutures, 
the former bringing about apposition of 
the muscles and deep fascia, the superficial layer bringing 
together the superficial fascia and skin (Fig. 200). These 
sutures may be applied so that the knot is covered by the 
tissues (Fig. 201). 

Deep or buried sutures are often employed to unite fascia, 
muscles or tendons and the best material for this variety of 
suture is either catgut, silk or kangaroo-tail tendon. 

Continued Suture. — This variety of suture is applied in the 
same manner as the interrupted suture, but the stitches are 
not cut apart and tied; it is made with silk or catgut (Fig. 
202), and is secured by drawing it double through the last 
stitch and using the free end to make a knot with the double 
portion attached to the needle (Fig. 204) . This suture may 




Interrupted suture. 



SUTURES 



259 



Fig. 200. 



Fig. 201. 





Buried sutures. 



Buried suture, applied so that the 
knot is covered. 



Fig. 202. 



Fig. 203. 





Continued or glovers' suture. 



Chain-stitch or button-hole suture. 



260 



MINOR SURGERY 



be used in intestinal wounds, but may also be employed in 
obtaining apposition of the edges of wounds in tissues of loose 
structure. 

Chain-stitch or Button-hole Suture. — This is a variety of 
continued suture which differs from the ordinary continued 
suture, in that the loop is made on one side of the wound as 
soon as the suture has been passed (Fig. 203) . 

Fig. 204. 




Method of securing continuous suture by tying free end and loop. 

Subcuticular Suture. — Halsted has introduced a suture in 
which the needle is introduced on the under surface of the 
skin on one side, and brought out just beneath the cut edge; 
it is then entered in the reverse direction below the epidermic 

Fig. 205. 




Subcuticular suture. 



surface opposite; when tied it will lie wholly out of sight. 
The object of this variety of suture is to avoid infection of 
the wound by the skin coccus, which may be introduced by 
the suture if passed from without inward. Fine silk or cat- 



SUTURES 261 

gut should be used for this variety of suture, which may 
become encysted, absorbed or gradually cast off after a few 
weeks. If employed as a continuous suture the free ends 
may be tied together and the suture subsequently removed 
by cutting the loop and drawing out the suture from one end 
of the wound (Fig. 205). 

The Twisted or Hare-lip Suture. — This is a very useful form 
of suture where great accuracy and firmness of apposition of 
the edges of the wound are desired. It is applied by thrusting 
pins or needles deeply through both lips of the wound, the 
edges being kept in contact over the wound by figure-of-eight 
turns with silk or wire (Fig. 206). The ends of the pins 
should be cut off with pin-cutters after the sutures are applied 
or should be protected by pieces of cork or plaster to prevent 
them from injuring the skin of the patient 
and causing him pain. The twisted or hare- FlG - 206 - 

lip suture is frequently employed in plastic 
operations about the face and in other parts 
of the body where accurate apposition of 
the flaps is important. 

Mattress or Quilt Suture. — This suture is 
applied by carrying the needle through the 
two flaps and then back again, so that a suture. 

loop is left on one side and the two ends of the 
suture project from the opposite flap (Fig. 207) . This variety 
of suture may be applied as an interrupted or as a continu- 
ous suture; in the latter, loops are made through the flaps 
on each side of the wound. 

Continuous Mattress Suture. — This variety of suture, known 
as the Cushing suture, is often employed as an intestinal 
suture, but does not result in as secure or close apposition of 
the edges of the wound as the interrupted mattress suture. 
It is applied as shown in Fig. 208. 

The Quilled Suture. — In making use of this suture a needle 
armed with a double thread of wire or silk is passed through 
the tissues as in applying the interrupted suture, but at a 
greater distance from the edges of the wound. Into the 
loops on one side of the wound is inserted a quill or piece of a 
flexible catheter or bougie, and on the opposite side the free 




262 



MINOR SURGERY 



ends of the sutures are tied around a similar object after being 
tightened (Fig. 209). This form of suture makes deep 



Fig. 207. 



Fig. 208. 





Mattress suture, interrupted. (Brewer.) 



Cushing suture. (Brewer.) 



equable pressure along the whole line of the wound. In 
applying this suture, it may be found advisable in some cases 



Fig. 209. 




The quilled suture. 




to introduce a few superficial interrupted sutures along the 
line of the wound to secure accurate approximation of the 



SUTURES 



263 



Fig. 210. 



skin. Two small rolls of sterilized or antiseptic gauze may 
be used as a substitute for the quills or pieces of catheter, as 
shown in Fig. 210. 

Button or Plate Suture. — This suture 
is applied by passing a needle armed 
with a double thread as in the case of 
the quilled suture, the ends of the 
suture being passed through the eyes 
of a button or through perforations 
in a lead plate before being threaded 
in the eye of the needle. After the 
suture prepared in this way has been 
passed through both sides of the 
wound the needle is removed and 
the free ends of the suture are passed 
through the eyes of a button or the 
perforations in a lead plate on the 
opposite side of the wound, and are 
tightened and secured (Fig. 211). In 
applying this form of suture small 

rolls of antiseptic gauze may be used instead of buttons, as 
shown in Fig. 212. This form of suture may be employed 
in deep wounds to accomplish the same purpose as the 




Modified quilled suture. 



Fig. 211. 





Button suture. 



Modified plate suture, using gauze pledgets. 



264 MINOR SURGERY 

quilled suture. It allows the cutaneous margins of the 
wound to remain free from compression, and here, as in the 
case of the quilled suture, a few interrupted sutures may be 
introduced between the button or plate sutures to secure 
accurate apposition of the skin surfaces if desired. 

Shotted Suture. — This suture receives its name not from any 
special method of application, but solely from the way in 
which it is secured ; any of the previously mentioned varieties 
of sutures may be employed. The material used in applying 
this suture may be catgut, silver wire, silkworm gut, silk or 
horsehair, and after the suture has been passed the needle 
is removed, and the ends are passed through a perforated 
shot; the ends are then drawn upon to bring the edges of the 
wound in contact, and the shot is pressed down to the skin 
and clamped by means of a shot compressor. The suture is 
then cut off flush with the surface of the shot. 

This method of securing sutures is especially useful in 
closing wounds in the mucous cavities, such as the vagina, 
rectum and mouth, where the knot or twist of the wire might 
cause irritation of the surface or pain to the patient; it is also 
a useful method of securing sutures in plastic operations; it 
also facilitates the removal of the sutures, as the shot is not 
apt to be obscured by the swollen tissue, and is easily seized 
by forceps when the loop is divided. 

Splint Suture. — These are frequently used in closing abdom- 
inal incisions in connection with layer sutures to eliminate 
dead spaces and furnish additional fixation to the edges of 
the wound. After the peritoneum has been closed by sutures 
a number of interrupted splint sutures of silkworm gut or 
linen are introduced about 1 or 1J inches apart. A large 
curved or straight needle carrying a strand of silkworm gut 
is passed through the skin about \ inch from the edge of the 
wound and carried down through all the tissues of the 
abdominal wall to the peritoneum and carried across the 
wound and out through all the structures of the abdominal 
wall on the other side to the skin surface. A number of 
these sutures are passed according to the length of the wound, 
and their ends are clamped and not tied at the time. After 
the aponeurotic layer of sutures has been applied the splint 



SUTURES 265 

sutures are pulled taut and tied without much tension; a few 
interrupted skin sutures may be required between the splint 
sutures to secure accurate closure of the wound. 

Fig. 213. 




The "splint sutures" have been inserted, and their ends are clamped. 
(Deaver and Ashhurst.) 

Removal of Sutures. — Where sutures are buried in the 
tissues or used to approximate parts in cavities which are 
subsequently closed, such materials should be used for sutures 
as will be absorbed in a few days, or will become encysted and 
remain harmless in the tissues — such as catgut, silkworm gut 
or silk — and it is needless to state that sutures used with this 
end in view should be rendered perfectly aseptic before being 
employed. 

Catgut sutures, when well prepared and used for sutures in 



266 MINOR SURGERY 

external wounds, usually undergo absorption in from ten to 
fifteen days; the loop buried in the tissues is absorbed, and 
the knot may be removed from the surface with forceps or 
it may come off with the dressings. 

The other substance, such as silk, silkworm gut, silver wire 
and horsehair, are removed by cutting one side of the loop 
and making traction upon the knot of the suture with forceps, 
or in the case of the wire suture, after dividing the loop and 
straightening out one end of it, the wire should be withdrawn 
in a curved direction. 

Sutures which are not causing irritation should be allowed 
to remain until the wound is solidly healed. The time 
usually required in case of aseptic wounds is from eight to 
twelve days. 

Fig. 214. 




Nerve suture: One passes through the end of the nerve; the others pass through 
the sheath only. (Ashhurst.) 



Nerve Suture. — For this suture fine chromic catgut or silk 
is threaded in a fine round needle and one suture is passed 
through each end of the divided nerve and tied just tight 
enough to approximate the ends of the nerve. Additional 
sutures should next be applied to the nerve sheath to approxi- 
mate this and prevent adhesion of the nerve fibers to sur- 
rounding structures (Fig. 214). 

Tendon Sutures. — The material employed for sutures may 
be silk, catgut or kangaroo tendon, and one or more sutures 
should be used, being passed through the substance of the 
ends of the tendon and secured by tying; the divided sheath 
of the tendon, if possible, should be brought together by fine 
silk sutures (Fig. 215). Very marked retraction of the ends 
of the tendon is liable to occur, and a considerable dissection 
is often required to bring them into view. 



SUTURES 



267 



When there is difficulty in bringing the ends of the tendon 
together, and the sutures are apt to cut out, the form of suture 
shown in Fig. 216 may be employed. 



Fig. 215. 




Suture passed through the substance of the ends of a divided tendon. 

Intestinal Sutures. — Sutures employed in wounds and opera- 
tions upon the intestines and hollow viscera are either of fine 
catgut, silk or celluloid thread. A round needle such as the 
ordinary sewing needle is used in preference to the bayonet- 
pointed needle, as it does not cut the tissues and there results 
less bleeding from the punctures. Two layers of sutures 
should be used when it is possible, the deep layer of sutures 
including the mucosa and the superficial layer, the serous 
and muscular coats. 

Fig. 216. 




Tendon suture which does not easily tear out. 

Accurate apposition of the edges of the bowel should be 
obtained to prevent leakage. This is especially important 
in wounds of the small intestine. 

Care should be taken that the lumen of the bowel is not 
materially reduced by the sutures. 

Lembert's Suture.— Lembert's suture is used in wounds of 
the viscera covered by the peritoneum, with the object of 



268 



MINOR SURGERY 



bringing in contact the peritoneal surfaces. This form of 
suture is usually employed in closing wounds of the intestine, 
bladder and stomach. 



Fig. 217. 



Fig. 218. 




Lembert's suture. 



Lembert's suture, a, serous; 6, 
muscular; c, mucous coat. 



Fig. 219. 



A needle armed with a fine catgut,' silk or celluloid thread 
is first carried through the peritoneal and muscular coats of 

the intestine a short distance from 
the wound, and it is then carried 
across the wound and passed 
. through the same portions of the 

Vh M w intestine a short distance from 

x"-^— • ffr' the edge of the wound on the 

opposite side (Fig. 217), and when 
the suture is tightened the peri- 
toneal surfaces of the intestine are 
inverted and brought into contact 
with each other (Fig. 218); the 
interrupted or continued suture 
may be employed in making this 
form of suture. 

Halsted's Mattress or Quilt Sut- 
ure. — This is a modification of 
Lembert's suture. The needle penetrates the peritoneal and 
muscular coats of the gut, including a small portion of the 





Halsted's quilt suture for intestine. 



SUTURES 



269 



Fig. 220. 
3 



submucosa, twice on each side of the wound and is then tied 
(Fig. 219). _ 

Purse-string Suture. — This form of suture is frequently used 
in operations upon the intestines and other abdominal viscera 
for covering in the stump of an 
appendix and in operations upon 
the gall-bladder and in securing 
the two sections of the Murphy 
button. It is applied by introduc- 
ing a continuous suture of silk or 
catgut, or celluloid thread, in a 
circular manner at a little distance 
from the part to be covered in, the 
stitches pick up the peritoneal and 
muscular coats at intervals, and 
when the part has been circum- 
scribed by tying the ends of the 
suture, the parts are puckered and bring the serous surface 
in contact over the part to be included (Fig. 220). 




A purse-string suture to close a 
perforation. (Ashhurst.) 



Fig. 221. 



Fig. 222. 





Czerny-Lembert suture. 
(Ashhurst.) 



Albert-Lembert suture not pulled tight. 
(Ashhurst.) 



Czerny-Lembert Suture. — This suture is a combination of 
the Czerny suture, which is a suture passed through all the 
coats of the bowel, and a Lembert suture, which includes 
only the serous and muscular coats of the bowel in its grasp 



270 MINOR SURGERY 

(Fig. 221). For the deep suture, which includes all the coats 
of the bowel, catgut should be used and the knots should be 
placed within the lumen of the bowel. Either of these sutures 
may be interrupted or continuous. The Albert Lembert 
suture, which includes all the tissues of the bowel and is 
knotted within the lumen of the bowel, is shown in Fig. 222. 
This suture may be employed in wounds or in end-to- end 
approximation or lateral anastomosis of the intestines. 



LIGATURES USED IN THE TREATMENT OF VASCULAR 

GROWTHS. 

Vascular growths were formerly very generally treated by 
ligation, but at the present time excision or destruction of the 
growth by roentgen ray, electrolysis or carbon dioxide is 
more frequently employed. 

Various forms of ligatures are used for the strangulation of 
vascular growths; the material employed is usually strong 
silk or hemp thread, catgut or silver wire. 

The Single Ligature with a Pin. — This is applied by first 
inserting a hare-lip pin through the skin near the edge of the 

growth, passing it under the 
Fig. 223. growth and bringing it out 

through the skin at a point 
opposite the place of entry; a 
strong silk or hemp ligature 
is passed under the ends of 
the pin surrounding the base 
of the tumor, and is drawn 

Vascular tumor strangulated with pin . 1 ' 

and ligature. tight enough to strangulate 

the growth, and is secured 
by two knots (Fig. 223). If the growth is of considerable 
size it is better before applying this ligature to introduce a 
second pin at right angles to the first one, and then secure the 
ligature under the pins. In applying these forms of ligature 
to healthy skin the patient is saved much pain, and the 
separation of the mass is hastened by cutting a groove in 
the skin with a sharp knife at the point where the ligature 




TREATMENT OF VASCULAR GROWTHS 



271 



is to be applied; the ligature when tied is buried in the 
groove thus made. 

Double Ligature. — This ligature is applied by passing a 
needle or a needle with a handle, armed with a double ligature, 



Fig. 224. 




Method of applying double ligature. (Roberts.) 



through the skin near the growth, and then passing it under 
the tumor and bringing it out through the skin at a point 
directly opposite the point of inser- 
tion; the ligature is then divided Fi g. 225. 
and the needle removed . The tumor 
is strangulated by tying firmly the 
corresponding ends of the ligature 
on each side of the tumor, each liga- 
ture including one-half of the growth 
(Fig. 224). 

The double ligature may also be 
applied by first passing a pin under 
the growth and then passing a needle 
armed with a double thread under 
the tumor at right angles to the pin, 
and after removing the needle the 
ends of the ligature are tied and 
the tumor is strangulated in two sec- 
tions (Fig. 225). 

Quadruple Ligature. — In apply- 
ing this ligature, two needles carry- 
ing a double thread are passed under the growth at right 
angles to each other; or if the handled needles be used, they 
may first be passed in this manner, and then threaded with 
double ligatures, which are carried under the growth as they 




Method of applying double 
ligature and pin. 



272 



MINOR SURGERY 



are withdrawn. The needles being removed, the surgeon ties 
two ends of the ligature together, and repeats this procedure 
until the growth has been strangulated in four sections. 

Subcutaneous Ligature.— This is applied by introducing a 
needle armed with a ligature through the skin near the 
growth, and carrying it through the subcutaneous tissues 
around the part to be constricted for a short distance, then 
bringing it out through the skin. The needle is again intro- 
duced through the same puncture, and is again brought out 
through the skin at some distance from the first point of exit. 
It is next introduced through this puncture and brought out 

Fig. 226. 




Method of applying subcutaneous ligature. 



at a more distant point. In this way the growth is com- 
pletely encircled by a subcutaneous ligature, which is finally 
brought out at the point of entrance; the tumor is strangu- 
lated by firmly tying together the ends of the ligature (Fig. 
226). 

If a needle armed with a double ligature is first passed 
under the growth the ligature is divided, and by passing each 
end of the divided ligature subcutaneously around the growth 
it may be strangulated subcutaneously in two sections. 

Carbon Dioxide. — The use of carbon dioxide has largely 
supplanted the various forms of ligatures used in the treat- 
ment of vascular growths. The drug in liquid form can be 



TREATMENT OF VASCULAR GROWTHS 273 

purchased in large cylinders. On opening the top the liquid 
escapes and evaporates so quickly that intense cold is pro- 
duced, which freezes the liquid into a soft snow. This is 
collected and pressed into a cylindrical form, and a solid 
stick of compressed snow results. This can be cut to the 
required shape, and is held firmly in contact with the growth 
from twenty to forty seconds. Upon removing the stick a 
depression is seen in the middle of the frozen area, which 
disappears in a few seconds when the tissues thaw. No 
anesthetic is required as the application is practically painless 
although the application is often followed by burning pain in 
the part. A sharp reaction follows the freezing, followed by 
blistering or even superficial ulceration. No after-treatment 
is required other than a simple dusting powder. 

Injection of Hot Water. — The treatment of vascular growths 
by the injection of boiling water has been advocated by 
Wyeth. A hypodermic syringe is filled with boiling water 
and the needle is passed deeply into the growth and boiling 
water is injected. The amount of water injected depends 
upon the size of the growth. In large growths sections of the 
growth may be injected at intervals of a few days. 

Elastic Ligatures. — Ligatures made of India-rubber varying 
from half a line to several lines in thickness are often made 
use of in surgery. They may be employed to strangulate 
growths such as moles or nevi, or in the treatment of fistulas, 
and are especially useful in the treatment of those cases of 
fistula-in-ano in which the internal opening into the bowel 
is situated high up, as the division of such fistulas by this 
means is accomplished without hemorrhage and with less 
risk than by the employment of the knife. In applying elas- 
tic ligatures in such cases the ligature, after being passed 
through the fistula by means of a probe, is carried out through 
the internal opening; the sphincter is next well stretched, 
and the elastic ligature is then firmly tied with two or three 
knots; the greater the tension made before the ligature is tied 
the more rapidly will it cut its way out. The smaller sizes 
of rubber drainage tubes may be substituted for the solid 
rubber ligatures. 

18 



274 MINOR SURGERY 

TREATMENT OF HEMORRHAGE. 

Hemorrhage may arise from wounds of arteries, veins or 
capillaries, or from simultaneous wound of these vessels. In 
arterial hemorrhage the blood is scarlet and escapes in jets 
from the proximal end of the vessel; the jets are synchronous 
with the heart beats, the stream never entirely intermits. 
That from the distal end is darker and does not pulsate 
unless the wound of the vessel is near a large collateral 
branch. In venous hemorrhage the blood is dark in hue 
and escapes in a continuous stream. In capillary hemor- 
rhage the blood is lighter in color than venous blood and 
wells into the wound from numerous fine points on its surface. 

Spontaneous arrest of hemorrhage is dependent upon the 
coagulation of blood, the retraction and contraction of the 
wounded bloodvessels, lowering of the blood-pressure by 
diminution of the volume of blood and increase in the coagu- 
lability of the blood from the progressive anemia. Women 
can stand the loss of a greater proportion of blood than men ; 
children, old people and individuals exhausted by disease or 
sepsis bear the loss of blood badly. The loss of from 4 to 6 
pounds of blood in an adult is usually fatal. The symptoms 
of the loss of a large quantity of blood are pallor of the face 
and lips, a frequent, small and fluttering pulse, the heart 
beats are weak and fluttering, the temperature is subnormal, 
the respirations are shallow and sighing and the skin is cold 
and clammy. Vertigo and nausea may be present. The 
pupils are dilated, and if the bleeding continues syncope 
occurs. 

The surgeon may be called upon to treat the following 
varieties of hemorrhage: arterial, venous, or capillary; and 
these again are classified according to the time of their 
occurrence, as primary — that is, bleeding which occurs at 
the time the wound is inflicted; intermediary or consecutive, 
that which occurs within twenty-four or forty-eight hours 
after the reception of the injury, and which generally takes 
place during the period of reaction; and secondary, which 
usually results from a septic condition of the wound, causing 
a septic arteritis, and occurs usually after forty-eight hours, 



TREATMENT OF HEMORRHAGE 275 

but may occur at any time subsequent to this period until 
the wound is healed. Subcutaneous hemorrhage may also 
occur from injury of arteries and veins. The blood may 
escape into the cellular tissue, or form a distinct tumor with 
fluctuation. If a large artery has been injured pulsation 
may be present in the tumor, producing a traumatic 
aneurysm. The treatment of hemorrhage is both constitu- 
tional and local. 

Constitutional Treatment. — The bleeding should be tempo- 
rarily arrested by pressure, sterile gauze packing, or by a 
tourniquet, if it arises from an accessible point, and no treat- 
ment should be given to bring about reaction until this has 
been accomplished. The treatment to bring about reaction 
consists in keeping the patient in the recumbent posture, 
with the head lowered. Heat should be applied to the sur- 
face of the body and the arms and legs bandaged up to the 
trunk to divert blood to the nerve centers. This is called auto- 
transfusion. Hot saline solution, coffee or stimulants should be 
given by enema. Hot saline solution, 1 pint, to which has been 
added 3 i of a 1 to 1000 solution of adrenalin, should be given 
intravenously or by hypodermoclysis, and is most efficient. 
Transfusion of blood, if a suitable donor is available, is of the 
greatest service. The hypodermic use of morphine, ^ gr., 
atropine, gr. ^q, or strychnine, gr. -^ (the latter is not as 
efficient as atropine), should be employed. Stimulants and 
liquid nourishment should be given by the mouth carefully, 
as they may not be absorbed and may cause vomiting. 

The hemostatic properties of gelatin have led to its use by 
subcutaneous injection in various forms of internal hemor- 
rhage. A sterilized aqueous solution, containing 2 per cent 
of gelatin in normal salt solution, is injected into the loose 
cellular tissue of the abdominal walls or buttock, about 
200 cc. being employed. It has been used in hemoptysis, epis- 
taxis and in intestinal hemorrhage in typhoid fever. 

Local Treatment. — This consists in the adoption of various 
local measures to control the bleeding, which may be either 
temporary or permanent in their action. 

Temporary Control of Arterial Hemorrhage. — This may be 
effected by pressure applied directly to the bleeding vessel 



276 



MINOR SURGERY 



in the wound or by pressure applied indirectly to the main 
artery between the point of its injury and the center of the 
circulation, and this pressure may be made by the fingers — 
digital compression — by compresses, or by means of tourni- 
quets. 

Digital Compression. — This constitutes one of the most valu- 
able means employed in the temporary control of hemorrhage : 
the finger is pressed directly upon the bleeding vessel, in the 
wound, or is used to make pressure upon the artery from 
which the bleeding arises at some point between the wound 
and the center of the circulation (Fig. 227). Control of 

Fig. 227. 




Digital compression of the femoral artery. 



hemorrhage by digital pressure can be maintained only for 
a few minutes, for the fingers of the surgeon or assistant 
soon become tired, so that it is employed only until means 
are adopted for permanent arrest of the bleeding. Digital 
compression of the radial and ulnar arteries may be resorted 
to for the control of hemorrhage during amputations of the 
fingers, of the axillary, subclavian and femoral arteries in 
amputations at the shoulder- joint and the hip-joint. It is 
also used to control hemorrhage from wounds either the 
result of accident or those made by the knife of the surgeon, 
in which case the finger is placed directly upon the divided 



TREATMENT OF HEMORRHAGE 



277 



Fig. 228. 



vessel or is employed to hold a sponge or compress firmly in 
the wound. 

Compresses.— By the use of compresses placed directly in 
the wound or applied to the vessel between the wound and 
the center of the circulation, the temporary control of hemor- 
rhage may be very satisfactorily accomplished. The com- 
press which is applied in the wound 
should be made of antiseptic or ster- 
ile gauze, thereby diminishing the 
chances of wound infection. The 
compress should be held in position 
by a bandage firmly applied, and is 
generally employed only as a tempo- 
rary expedient until a more perma- 
nent means of controlling the bleed- 
ing is adopted. 

Tourniquets. — These instruments, 
which are employed for the tempo- 
rary control of hemorrhage from 
wounds, are of many different kinds. 

Petit's Tourniquet. — This consists 
of two metal plates connected by a 
strong linen or silk strap, with a 
buckle, the distance between the 
plates being regulated by a screw 
(Fig. 228). In applying this tourni- 
quet a compress or roller bandage is 
placed directly over the artery to be 
compressed, and may be held in posi- 
tion by a few turns of the bandage. 

The lower plate of the tourniquet is placed directly over this 
pad, and the strap is tightly secured around the limb to keep 
the instrument in place. The screw is then turned so as to 
separate the plates and tighten the strap, thus forcing the 
compress or pad upon the artery and controlling its circula- 
tion. This instrument is very generally employed for the 
control of hemorrhage in wounds of the extremities, and is 
especially useful in amputation of these parts, being placed 
over the main artery some distance above the seat of oper- 
ation. 




Petit's tourniquet applied to 
femoral artery- (Ashhurst.) 



278 



MINOR SURGERY 



The Spanish Windlass. — An improvised tourniquet, known 
as the Spanish windlass, may be employed in cases of emer- 
gency; it is prepared by folding a handkerchief or piece of 
muslin into a cravat and placing a compress or smooth pebble 
on the body of the cravat; this is placed over the artery to 
be controlled, and the ends of the handkerchief are tied 
loosely around the limb; a short stick is passed through this 
loop, and by twisting the stick the loop is tightened and the 

compress is forced down upon the 
Fig. 229. artery (Fig. 229). 

Many other forms of tourniquet 
have been devised which have the 
pad and counter-pad arranged to 
make pressure upon the vessel, 

Fig. 230. 





The Spanish windlass. 



Lister's aorta compressor. 



such as Lister's aorta compressor (Fig. 230), w x hich was em- 
ployed in the treatment of aneurysm of the iliac vessels and 
for the control of hemorrhage in amputation at the hip-joint. 
Signorini's tourniquet (Fig. 231) is constructed upon the 
same principle, and was frequently employed to control the 
circulation in the femoral artery in cases of operations on 
the thigh and leg and in the treatment of femoral or pop- 
liteal aneurysm. 



TREATMENT OF HEMORRHAGE 



279 



Elastic Constriction. — The elastic tube, or the strap of 
Esmarch's apparatus (Fig. 232), may also be employed for 
the temporary control of arterial hemorrhage, being applied 
above the wound; and if it is not at hand any strong rubber 
cord or a piece. of large-sized drainage tube may be used as a 
substitute. Elastic suspenders or garters may also be 
employed in an emergency. In hemorrhage from wounds of 
the hands and feet, especially in children, and in controlling 
hemorrhage from wounds of the penis, a piece of drainage 

tube, firmly applied above the 
wound, may be employed with 
advantage. Care should be ob- 
served in applying elastic constric- 
tion, for if the elastic tube be ap- 
plied too tightly the subcutaneous 
tissues may be divided or nerves may 

Fig. 232. 



Fig. 231. 





Signorini's tourniquet. 



Elastic strap of Esmarch's apparatus. 



be so compressed that their function is destroyed. The tube 
or strap, although generally employed to control hemorrhage 
from the vessels of the extremities, may be used to control the 
femoral artery as it crosses the brim of the pelvis, by placing 
a compress over the artery in this position, and then applying 
the elastic band to secure it by making a figure-of-eight turn, 
passing under the thigh, crossing over the pad and then carry- 
ing the ends around the pelvis and securing them. 

To make pressure on the axillary artery a compress should 
be placed in the axilla, and the middle of the tube placed 



280 



MINOR SURGERY 



over this to hold it in position; the ends of the tube are then 
carried over the shoulder, where they are crossed and then 
carried to the opposite axilla and secured. 

Hemostatic Forceps. — The temporary control of arterial 
hemorrhage by the use of hemostatic forceps is now very 
generally employed in surgical operations, and their use has 
done much to diminish the shock following operations from 
the loss of blood. The hemostatic forceps in general use" is 
self -retaining; it is clamped upon the bleeding vessel, and is 
allowed to remain until the operation is completed, when the 
vessel is secured permanently by the application of a ligature, 
and the forceps is removed. The use of these forceps will be 

Fig. 233. 




Hemostatic forceps. 



found very satisfactory in controlling hemorrhage during 
the removal of tumors; in amputations and for the temporary 
control of bleeding during the operation of tracheotomy, they 
will be found most efficient, as also in abdominal operations, 
in which their utility was first demonstrated (Fig. 233) . 

Esmarch's Bandage and Tube. — This apparatus, which is 
applied to the limbs to render them bloodless during opera- 
tions, consists of a rubber bandage 2J inches in width and 
3 or 4 yards in length, and a rubber tube 2 yards in length, 
to one end of which is attached a chain and to the other a 
hook, or, better, a rubber strap, 1 inch in width and 1 J yards 
in length, with a hook and chain. The bandage is applied 



TREATMENT OF HEMORRHAGE 



281 



to the extremity of the limb, and is carried up the limb to a 
point some distance above the seat of proposed operation; 
the bandage is applied firmly, each turn overlapping one- 
fourth of the preceding one, and when the last turn has been 
made the rubber tube or strap is wound firmly around the 
limb and secured by fastening the hook into one of the links 
of the chain (Fig. 234) . After securing the tube or strap the 
rubber bandage is removed from the limb; and if the tube 
has been sufficiently firmly applied the limb will be found 
blanched, and should be free from blood during the operation. 
Care should be taken not to apply the tube or strap too 
tightly upon poorly developed limbs, or on parts of the limb 
where large nerve trunks approach the surface, as they may 



Fig. 234. 




Esmarch's bandage and tube applied. 

be subjected to an amount of pressure which will interfere 
with their functions subsequently. I have knowledge of one 
case of this nature in which permanent paralysis of the limb 
followed the use of Esmarch's apparatus; the tube should be 
applied with just sufficient firmness to control the circulation. 
As the strap, when firmly applied, completely cuts off the 
circulation of the parts below, it should be applied for as 
short a time as possible, as gangrene has resulted from its pro- 
longed use. After removal of the tube or strap there is 
generally free capillary hemorrhage, due to paralysis of the 
vasomotor nerves from pressure, but this in a short time 
stops. This appliance is of the greatest service in controlling 
hemorrhage at the time of operation, and in amputations and 



282 MINOR SURGERY 

for removal of vascular tumors from the limbs will be found 
most satisfactory. In operations upon bones, such as resec- 
tion or sequestrotomy, it is especially useful, as it allows the 
surgeon to inspect the parts unobscured by hemorrhage. I 
have found its use most satisfactory in operations for the 
removal of foreign bodies, such as needles embedded in 
extremities. 

Permanent Control of Arterial Hemorrhage. — To secure 
this end, the surgeon may resort to the use of position, cold, 
heat, styptics, pressure, cauterization, ligation, torsion, suture 
of the artery. 

Position. — In arterial hemorrhage from wounds of the 
extremities, elevation of the part will be found to materially 
diminish the amount of bleeding; in hemorrhage from wounds 
of the arteries of the hand, forearm, foot or leg, forcible flexion 
of the forearm on the arm or of the leg on the thigh will 
be found useful in diminishing the force of the blood cur- 
rent. 

Cold. — The application of cold by means of a stream of cold 
water or an ice-bag or pieces of ice will often be found an 
efficient means of controlling hemorrhage from vessels of small 
caliber; it is especially applicable to hemorrhage from wounds 
of the vessels of the mouth, nostrils, vagina or rectum. 

Hot Water. — Hot water will be found a very efficient means 
of controlling hemorrhage from small vessels, and it may be 
used in the form of a hot antiseptic solution. It is of special 
value in capillary or parenchymatous hemorrhage, and is 
employed in the form of a douche or by means of sponges or 
gauze pads dipped in the hot solution and packed into the 
wound. The injection of hot water is a most satisfactory 
method of controlling uterine hemorrhage. 

Styptics. — These agents are sometimes employed to control 
capillary bleeding or hemorrhage from small vessels, and 
although their use is often satisfactory as regards the control 
of the bleeding, they have the disadvantage of interfering 
with primary union in wounds, and since the value of asepsis 
in wound treatment has been demonstrated they are now very 
seldom employed. The most valuable styptics are alcohol, 
alum, oil of turpentine, perchloride of iron, persulphate of 



TREATMENT OF HEMORRHAGE 283 

iron or Monsel's solution, acetic acid, vinegar, adrenalin 
chloride, antipyrin and gelatin. 

Adrenalin Chloride. — A solution of adrenalin chloride in 
normal salt solution 1 : 1000 to 1 : 10,000 is employed for the 
control of hemorrhage. It seems to be most serviceable in 
capillary hemorrhage. It is extensively employed to check 
bleeding during operations upon the nose, throat and larynx 
and to arrest epistaxis and bleeding from the uterus. It is 
also used intravenously in profuse hemorrhages in combina- 
tion with saline solution. It is generally used by soaking a 
pledget of cotton or gauze in the solution and pressing it 
upon the bleeding surface; it may also be sprayed upon the 
part. Adrenalin extract, in the form of powder, may also be 
dusted upon a bleeding surface to secure hemostasis. 

Calcium Chloride. — This drug given internally favors the 
coagulation of blood and tends to check oozing. The initial 
dose should be 10 grs., and should afterward be given in doses 
of 5 grs. every hour until five or six doses have been taken. 

Antipyrin. — A solution of antipyrin, 5 per cent, in sterilized 
water possesses marked styptic action. As it also possesses 
antiseptic properties, and is not toxic, it may be used to con- 
trol capillary bleeding from the surface of the brain, the intes- 
tines and peritoneum and from the bone cavities. 

Gelatin. — This may be used as a styptic where it can be 
applied locally in 2 to 10 per cent solution in normal salt 
solution. Gelatin solution is prepared by taking 5 gm. of 
common salt, 1 liter of distilled water, 100 gm. of gelatin; 
bring the water to 80° C. and slowly stir in the gelatin until it 
is dissolved. Cool the solution to 40° C, add the white of 
one egg and stir for several minutes and then boil it; the 
white of egg coagulates and clears the solution. Filter 
through gauze and paper and put the solution in test tubes, 
each of which should contain 10 cc and close with a cotton 
plug. Sterilize by putting in a steam sterilizer fifteen minutes 
for three successive days. Before using a tube place it in hot 
water until the gelatin liquifies and it may be applied by 
injecting, irrigating or tamponing the bleeding area. It may 
also be injected subcutaneously. Intravenous injection of 
gelatin solution is dangerous, as it is apt to be followed by 



284 MINOR SURGERY 

embolism. It has been employed successfully in epistaxis, 
hematemesis, vesical and uterine hemorrhage and in super- 
ficial wounds in patients the subjects of hemophilia. 

Blood Serum. — This is obtained from human blood or that 
of animals; the former is to be preferred. Applied to the 
bleeding surface it hastens coagulation; it may also be used 
subcutaneously or intravenously in doses of 10 to 40 cc. It 
has been used with good results in hemophilia and in the post- 
operative oozing of jaundiced patients, or may be injected 
before the operation in these patients. 

Pressure.— For the permanent control of arterial hemor- 
rhage, pressure may be applied directly to the bleeding point 
or surface by means of a compress of aseptic gauze or by 
strips of gauze packed firmly into the cavity from whose 
surface the bleeding arises. 

Compresses are used with the best results where the 
proximity of a bone gives a firm substance upon which the 
vessel may be compressed, as is the case in the vessels of the 
scalp. Pressure applied by means of packing with strips of 
gauze will be found most efficient in controlling hemorrhage 
from cavities, such as the nose, vagina or rectum, and in the 
cavities resulting from the removal of necrosed or carious 
bone. Pressure may be indirectly applied to an artery by 
flexing the joint over a compress or by firm bandaging of the 
limb. 

In controlling bleeding from a divided artery in a bony 
cavity, such as the inferior dental, a, piece of catgut ligature 
may be forced into the canal, and will control the bleeding 
in a most satisfactory manner, or it may be controlled by 
forcing a small piece of Horsley's wax into the opening in 
the bone; this wax is composed of wax, 7 parts; oil, 2 parts; 
and carbolic acid, 1 part. 

Bleeding from small vessels in the bone in dense fibrous 
tissues may be controlled by a muscle graft which consists of 
a small fragment of muscle which is forced into the cavity 
or held firmly for a few seconds against the bleeding-point. 

Halsted has introduced a material known as gut wool, which 
is prepared from the same material from which catgut is 
made. This is cut into fine shreds, and is used to control 



TREATMENT OF HEMORRHAGE 285 

hemorrhage from bone, being pressed into the opening or 
cavity in the bone from which the bleeding arises. 

The troublesome hemorrhage sometimes occurring after 
the removal of a tooth may be controlled by packing the alveo- 
lar cavity with a strip of iodoform gauze, or by introducing a 
wedged-shaped piece of cork and holding it in place by fasten- 
ing the jaws together by means of a bandage. 

Cauterization. — The use of cauterization by means of a hot 
iron is a satisfactory method of arresting hemorrhage. Care 
should be taken to have the iron only of a dull-red or black 
heat, as the result desired is not the destruction of the tissues, 
but the coagulating effect of heat upon them. The form of 
cautery-iron employed will depend upon the size and position 
of the vessel. Paquelin's cautery is also a satisfactory appa- 
ratus to use for the control of hemorrhage. 

The control of arterial bleeding by cauterization is often 
resorted to in operations upon the jaws and in the removal 
of tumors from the mouth or pharynx or of the tonsils; it is 
also frequently employed to control hemorrhage in operations 
upon the uterus and the rectum, and also that resulting from 
the removal of abdominal tumors, where the application of a 
ligature is difficult and often impossible. 

Torsion. — This method of controlling arterial hemorrhage 
consists in seizing the end of the artery, drawing it slightly 
out of its sheath and twisting it; it may be accomplished with 
a single pair of forceps or hemostatic forceps, or by two pairs 
of forceps. In the latter method the vessel is held by one 
pair of forceps and is twisted by the second pair. It should 
only be used in vessels of moderate size. 

Torsion of arteries in accidental wounds is quite common, 
and in many cases controls the hemorrhage until surgical aid 
is rendered. I have seen hemorrhage from the femoral artery 
in Scarpa's triangle completely controlled in this manner in a 
case of avulsion of the thigh from a railway injury. 

The Ligature. — The use of the ligature is by far the most 
generally employed method of controlling arterial hemor- 
rhage. The materials used are silk, hemp thread or catgut. 
Catgut or silk is the material generally employed. The 
vessel is seized with a pair of hemostatic forceps and drawn 



286 



MINOR SURGERY 



out of its sheath, and a ligature of sterilized catgut or silk is 
thrown around it and secured by a surgeon's knot, or by a 
reef knot and a surgeon's knot combined and when firmly 
tied the ends of the ligature are cut short in the wound. 

When ligatures are applied to vessels in their continuity, 
they may be threaded into an eyed probe or aneurysm needle 
(Fig. 235) and carried around the vessel and secured. 

Fig. 235. 




Aneurysm needle armed with ligature. 



Temporary or Provisional Ligation of Arteries. — This pro- 
cedure is employed when it is desired to control for a time the 
arterial circulation during an operation, or as a precaution in 
case where free hemorrhage may occur. 

The artery to be temporarily occluded is exposed by a 
careful dissection. The sheath is not opened and a flat liga- 
ture or tape is passed beneath the sheath and is closely tied 
or clamped with forceps. When it is desired to occlude the 
vessel, an assistant lifts the vessel from its bed by the ligature, 
which arrests the flow of blood through the vessel. When 
the necessity for the control of the circulation has passed the 
ligature is removed and the wound is closed. 

Special forceps or clamps with blades covered by rubber so 
that they cause no injury to the walls of the vessel may also 
be employed to secure temporary control of the circulation 
through the artery. 

Ligature En Masse or Suture Ligature. — A convenient method 
of applying a ligature to a bleeding point, or a limited area of 
hemorrhage in a deep wound, or to a vessel in tissues which 
are of such a nature as not to permit of the isolation of the 
vessel, is to use a curved needle threaded with a catgut liga- 



TREATMENT OF HEMORRHAGE 



287 




Artery occluded by suture ligature. 



ture, which is passed deeply into the tissues near the vessels 

and brought out on the opposite side; the ligature thus 

placed is then tied firmly enough to control the bleeding, but 

not so tight as to produce 

strangulation of the tissues; the F IG# 2 36. 

ends are cut short in the wound 

(Fig. 236). 

Arteriorraphy. — Suture of 
Arteries. — Wounds of arteries, 
both longitudinal, oblique and 
transverse, have been success- 
fully, closed by sutures both in 
man and the lower animals. 
It is recommended in the 
larger arteries, where more than 
two-thirds of the circumference 
has been divided to resect the 

injured portion of the vessel, where it can be done without 
removing more than f inch of the vessel, and invaginate one 
end into the other, and to secure their fixation by fine silk 
or catgut sutures, which include all the coats of the vessel 
(Fig. 237). The distal end of the vessel is slit for a short 
distance to aid in the invagination, which is accomplished by 
traction upon the sutures. When this is accomplished the 
sutures are tied tightly with reef knots. The line of juncture 
is reinforced by sutures uniting the edges of the slit formed 
so as not to include the intima or the invaginated vessel. In 
longitudinal wounds the edges may be brought together by 
fine silk sutures, introduced by means of a fine cambric needle. 
The sutures should be inserted from j-q to ■£$■ inch apart, and 
Yt inch from the edges of the wound, and should include only 
the adventitia and media, not perforating the intima (Fig. 
238). During the operation the circulation in the vessel 
should be controlled both above and below the wound by 
forceps covered with rubber tubing, Crile's clamps or tempo- 
rary ligatures. Where a distinct sheath is present, it should 
be sutured over the wound; and if this is not present, muscle 
or fascia should be sutured over the closed wound in the 
vessel. The application of sutures to wounds of arteries has 



288 



MINOR SURGERY 



been advocated to secure permeability of the vessel at the 
seat of the wound, but it is still a mooted question whether 
the vessel remains ultimately permeable at the seat of the 
wound. If thrombosis occurs at the seat of injury occlusion 
of the artery may be so gradual that gangrene will be much 
less apt to ensue than after ligation. 



Fig. 237. 



Fig. 238. 





Invagination of wounded artery. 
(Bickham.) 



Suture of longitudinal wound of an artery. 
(Bickham.) 



Closure by Plaster Tape. — Brewer, in experiments upon 
wounds of the arteries in animals, has secured control of the 
bleeding and closure of the wound by wrapping around the 
wounded vessel a strip of specially prepared adhesive plaster. 
The plaster is a variety of rubber plaster which has been 
thoroughly sterilized, so that it can remain indefinitely in the 
tissues. He has suggested that this procedure may be 
employed in wounds of the larger arteries in man, where for 
any reason sutures cannot be applied. 



TREATMENT OF HEMORRHAGE 289 

Rules for Ligating Wounded Arteries. — In cases of primary 
hemorrhage no operation should be performed upon an artery 
unless it is at the moment actually bleeding. The exception 
to this rule is in the cases where the vessel is seen to pulsate 
in the wound, or where the wound involves the region of a 
large artery and the patient has to be transported, or may be 
in a position not to receive surgical aid subsequently if needed; 
under these circumstances the vessel should be tied or the 
wound should be explored to ascertain the fact that no import- 
ant vessel has been injured. Arteriorraphy or circular 
invagination should be practised in suitable cases. 

In applying a ligature to a wounded artery the surgeon 
should cut down directly upon it at the point from which it 
bleeds and secure it in the wound. This rule holds good for 
both primary and secondary hemorrhage. 

Two ligatures should be applied, one to each end of the 
artery if it be completely divided, and one on each side of 
the wound if the latter has not severed all the coats of the 
artery. This procedure is adopted for the reason that arterial 
anastomosis is so free that the proximal ligature will not 
always, even temporarily, arrest the bleeding; and if it does 
accomplish this object at the time, after the collateral circu- 
lation is established bleeding is apt to occur from the distal 
extremity of the divided vessel. If the coats of the artery 
are not completely severed their division should be com- 
pleted, either before or after the application of the proximal 
and distal ligatures, thereby favoring contraction and retrac- 
tion of the ends of the divided vessel. If a branch is present 
just below the ligature tie the branch as well as the main 
vessel. If a branch is divided very near to the main artery it 
should be tied; the main vessel need not be ligated. 

Treatment of Venous Hemorrhage. — Bleeding from small 
veins often stops spontaneously unless there is pressure upon 
the wounded veins on the cardiac side of the wound. It is, 
however, very satisfactorily controlled by position or by the 
application of a compress and bandage. The free bleeding 
arising from ruptured varicose veins of the leg is easily con- 
trolled by the application of a compress and a bandage. 

19 



290 



MINOR SURGERY 



The Ligature. — When large veins have been divided both 
ends should be secured by ligatures, as in the case of divided 
arteries; small wounds should be treated by the lateral 
ligature or suture. 

The Lateral Ligature. — The application of the lateral liga- 
ture to small wounds of large veins, such as the femoral, or to 
wounds of venous sinuses, has been recommended and 
employed with good results; this procedure consists in 
pinching up the wall of the vein so as to include the orifice 
of the wound with forceps and throwing a delicate silk or 
catgut ligature around it (Fig. 239) . 

Fig. 239. 




Lateral ligature. (Bickham.) 



Phleborraphy. — Suture of Veins. — This procedure has also 
been employed with success in the case of longitudinal or 
transverse wounds of the larger veins. The bleeding should 
be controlled by pressure upon the vein on both sides of the 
wound, and the wound in the vessel should be closed by fine 
silk or catgut sutures applied closely together by means of a 
fine cambric needle (Fig. 240). The employment of sutures 
and lateral ligatures in wounds or veins possesses the advan- 
tage of controlling the bleeding and at the same time not 
causing obliteration of the vessel at the seat of injury. 



TREATMENT OF HEMORRHAGE 



291 



The actual cautery may also be employed for the control of 
venous hemorrhage in situations in which its arrest by pres- 
sure suture or the ligature is not feasible. 

Compression by means of strips of sterilized gauze is often 
employed to control venous hemorrhage from cavities. This 
is the most satisfactory manner of controlling hemorrhage 
for the venous sinuses of the brain. 

Fig. 240. 




Suture of a vein. (Bickham.) 



Treatment of Capillary Hemorrhage. — Capillary or paren- 
chymatous hemorrhage is often arrested spontaneously on 
exposure of the surface of the wound to the air, but the bleed- 
ing may not be controlled and may be so profuse that its 
arrest becomes a matter of importance. To control this form 
of bleeding, pressure may be applied to the bleeding surface 
for a short time, and if this fails to arrest it sponging the 
surface with dilute alcohol will sometimes prove satisfactory; 
but the best application to arrest hemorrhage of this nature 
is hot water or by hot compresses wrung out of hot water or 
hot saline solution. 

Adrenalin chloride solution, 1 to 1000 to 1 to 10,000, may 
also be employed with good results. 

In cases where the means mentioned above fail to control 
the bleeding it may be necessary to pack the wound with 
strips of sterilized gauze; this dressing is most serviceable 
when the hemorrhage comes from cavities such as result from 
the removal of tumors or excisions of joints, and for the 



292 MINOR SURGERY 

control of bleeding following the removal of necrosed or 
carious bone. To control hemorrhage from mucous cavities, 
such as the nose, rectum and vagina, this method of treatment 
is also frequently resorted to. 

Consecutive or Reactionary Hemorrhage. — This variety 
of hemorrhage develops during reaction from an accidental 
wound or operation in from twelve to forty-eight hours. It 
arises from vessels which did not bleed during the stage of 
shock or from vessels which were overlooked when the wound 
was dressed. It may also be due to improperly applied or 
prematurely softened ligatures. This form of bleeding is not 
often sudden or severe, the blood usually escaping by drops, 
and the constitutional symptoms of hemorrhage do not 
develop unless a considerable quantity of blood is lost. 

Treatment. — Pressure applied to the wound and elevation 
of the part, if possible, will often control the bleeding. If, 
however, the bleeding persists the wound should be opened 
and the bleeding vessels found and secured by ligatures. 

Treatment of Secondary Hemorrhage. — Secondary hemor- 
rhage following the use of the ligature or other means of 
controlling bleeding usually results from a septic condition of 
the wound, and is due to a septic arteritis. Since the adop- 
tion of the antiseptic and aseptic methods of wound treat- 
ment it is a much less frequent complication of wounds. 

The treatment of this complication is both constitutional 
and local. The constitutional treatment consists in the use of 
those remedies which were mentioned as serviceable in 
primary hemorrhage, and the drugs upon which most reliance 
should be placed are morphine, atropine and strychnine. 

The local treatment of this form of hemorrhage consists in 
the use of the various means of controlling hemorrhage which 
have been mentioned, such as the ligature, hot water, pres- 
sure or the actual cautery. If possible, it is well to secure 
the vessel from which the bleeding arises in the wound; if 
for any reason this cannot be done the main artery should be 
ligated above the wound if the hemorrhage be arterial. 

Subcutaneous Hemorrhage. — Hematoma. — Rupture of a 
large bloodvessel subcutaneously may give rise to a tumor 
and the constitutional symptoms of hemorrhage. If the 



TREATMENT OF HEMORRHAGE 293 

source of bleeding is from a ruptured artery pulsation may be 
present in the tumor. Hemorrhage from a ruptured vein 
may cause a distinct tumor, with fluctuation but without 
pulsation. 

Small effusions of blood are usually absorbed under rest and 
moderate pressure by a bandage. If the effusion is large and 
fluctuation persists the tumor may be aspirated or incised 
with full aseptic precautions, and the blood allowed to escape, 
the wound being closed without drainage. 

Control of Hemorrhage from Special Parts. — Epistaxis. — 
Epistaxis, or hemorrhage from the nose, may be so profuse 
as to require surgical interference. To control this form of 
hemorrhage the application of iced compresses to the surface 
of the nose may first be made use of, or the injection of cold 
sterile water, or pledgets of cotton or gauze saturated with 
adrenalin solution may be packed into the nasal cavity. If 
this fails to control the bleeding the surgeon or the patient 
should grasp the cartilaginous portion of the nose with his 
thumb and forefinger in such a manner as to keep the nostrils 
tightly closed, which will prevent the passage of air through 
the nose and thus permit clots to form, arresting the flow of 
blood. Bleeding from the nose often arises from the erosion 
of a small artery low down upon the septum which can be 
freely exposed by introducing a nasal speculum, and the 
bleeding point may be touched with a cautery iron, thus 
avoiding the necessity of plugging the nares. If these simple 
means fail to arrest the bleeding the nasal cavity or cavities 
may be packed with strips of sterilized gauze introduced into 
the anterior nares, and pushed backward by a director or 
probe; this will often be found a satisfactory means of arresting 
the bleeding. This method may be supplemented by a plug 
of sterilized cotton introduced into the posterior nares with 
the finger. The use of a rubber tampon, consisting of a 
rubber bag, introduced into the nares in a collapsed state 
and afterward inflated, has also been recommended for the 
control of this variety of hemorrhage. 

Plugging the nares by means of Bellocq's cannula is also 
employed to arrest hemorrhage from the nasal cavities; the 
cannula, armed with a strong ligature, is passed along the 



294 



MINOR SURGERY 



floor of the nose until it reaches the pharynx, when the spring 
being protruded, the ligature is seized and brought out of 
the mouth and secured to a plug of lint or of antiseptic gauze 
of the required size, and upon withdrawing the instrument 
the plug is brought into position in the posterior nares and 
the end of the ligature allowed to protrude from the mouth 
to facilitate its removal (Fig. 241). An ordinary flexible 
catheter may be employed instead of Bellocq's cannula for 
the introduction of the ligature. 



Fig. 241. 




Plugging the posterior nares. (Ashhurst.) 

Hemorrhage from the Urethra. — In hemorrhage from the 
urethra, if profuse, the blood will trickle from the meatus; 
or if efforts at micturition are made the first portion of urine 
will contain blood, but afterward will be clear, and the last 
portion will contain a few. drops of pure blood. 

This variety of bleeding, if it proceeds from the anterior 
portion of the urethra, may be controlled by the introduction 
of a catheter and the application of a bandage around the 
penis applied so as to make only moderate pressure. 

If the bleeding comes from the posterior portion of the 
urethra it will often be controlled by the application of cold 
or pressure to the perineum, or by the introduction of a cold 
steel bougie, or by the injection of a weak solution of antipyrin 
or of adrenalin solution. 



TREATMENT OF HEMORRHAGE 295 

Hemorrhage from the Bladder. — In this variety of hemor- 
rhage the first portion of the urine may be blood stained, and 
the last portion will contain more blood and clots as the 
organ contracts, which distinguishes it from hemorrhage from 
the kidneys, in which admixture of blood with the urine 
renders it of a smoky color or dark red if the bleeding is 
profuse. 

To control bleeding from the bladder a catheter should be 
introduced and the urine and clots withdrawn; the bladder 
should next be washed out with a hot boric acid solution. In 
severe cases a weak solution of antipyrin, alum or adrenalin 
may be employed. The application of ice to the perineum 
and suprapubic regions may also be employed with advantage. 

Hemorrhage from the Prostate Gland. — This requires the 
injection of hot boric acid solution and the introduction of a 
large warmed bougie. A catheter should be introduced and 
tied in the bladder for several days. 

Hemorrhage of the Kidney. — This may follow wounds of the 
kidney or contusion of the organ. Bleeding following contu- 
sions of the kidney is not usually profuse, and generally sub- 
sides with rest in bed, the application of an ice-bag to the 
loin, and the use of 10-gr. doses of gallic acid. Cystoscopic 
examination may be required to determine from which kidney 
the bleeding comes. If the bleeding continues the kidney 
should be exposed by lumbar incision, and the wound sutured 
or nephrectomy should be performed. 

Hemorrhage of the Stomach. — Bleeding from the stomach 
should be treated by the use of ice and the administration of 
opium and gallic acid or gelatin solution; if it persists the 
stomach should be exposed by laparotomy, and if an ulcer 
is located it should be excised. Hemorrhage from a wound 
calls for laparotomy and treatment of the wound. Profuse 
hemorrhage from the stomach may arise from cirrhosis of 
the liver; in such a case operative treatment is useless. 

Hemorrhage of the Rectum. — This variety of bleeding may 
be controlled by the injection of cold or astringent enemata. 
If the bleeding be profuse a speculum should be introduced, 
and when the source of the bleeding has been discovered the 
actual cautery or a ligature should be applied. If this is not 



296 MINOR SURGERY 

feasible the rectum may be plugged with strips of antiseptic 
gauze, or a piece of a rubber catheter of large caliber, or a 
rubber tube, may be wrapped with gauze and introduced 
into the rectum, the end of the catheter being allowed to 
protrude; by using this tube flatus can escape, and if the 
bleeding is not controlled blood will escape through the tube, 
preventing the risk of concealed hemorrhage. If the bleeding 
arises from hemorrhoids or polypus of the rectum, operative 
treatment of these conditions should be undertaken to remove 
the cause of bleeding. 

Intra-abdominal Hemorrhage. — In this variety of hemor- 
rhage the constitutional symptoms are very marked. It may 
arise from contusions or wounds of the abdomen, producing 
lacerations or wounds of the solid or hollow viscera. The 
blood may gravitate to the loins, causing dulness on percus- 
sion, which changes as the patient's position is changed, or 
it may settle in the recto- vesical or recto-uterine pouches. In 
wounds of the spleen the area of dulness remains in the splenic 
region as the blood clots quickly. The treatment consists 
in an exploratory laparotomy and search for the source of 
bleeding. Wounds of the hollow viscera should be sutured; 
those of the solid viscera sutured, cauterized or packed to 
control the bleeding. Severe wounds of the spleen require 
splenectomy. Wounds of the kidney may be sutured, or may 
require partial or complete nephrectomy. Wounds of the 
mesenteric vessels should be ligated, and if a portion of the 
intestine is deprived of blood, resection should be performed. 

Extradural Hemorrhage. — This usually arises from the 
middle or anterior meningeal arteries. The symptoms deter- 
mine the site of the lesion. To expose the middle meningeal 
artery, open the skull at a point on a level with the upper 
orbital border and 1 J inches behind the external angular pro- 
cess, and if no clot is exposed, trephine over the posterior 
branch on the same level and just below the parietal emi- 
nence. Remove the clot and close the wound. 

Hemophilia. — This is a congenital affection in which there 
is an abnormal and inveterate tendency to hemorrhage from 
trifling injuries, such as the extraction of a tooth or insignifi- 
cant wounds or abrasions; spontaneous bleeding may also 



TREATMENT OF HEMORRHAGE 297 

occur from the mucous membranes. This condition affects 
males almost exclusively, but is transmitted from one genera- 
tion to another only through the female; such individuals are 
known as bleeders and the existence of the condition is estab- 
lished soon after birth by the persistent oozing which occurs 
after minor injuries. Such slight injuries in hemophiliacs have 
been followed by death from acute anemia. The blood in 
this condition is not coagulable, or only very feebly so. 
Operations should be avoided in bleeders unless absolutely 
necessary. In such cases blood transfusion from a healthy 
individual is indicated in order to provide the elements of 
blood necessary for coagulation. The* subcutaneous injection 
of 20 to 30 cc of suitable blood forty-eight hours before 
operation has been used and is said to arrest or diminish the 
bleeding. Hemorrhage from the larger vessels is easily 
arrested by ligature, but capillary oozing continues, and no 
local treatment seems to avail in controlling it. 

Treatment. — The subcutaneous injection of horse serum 
and even diphtheria antitoxin has been used in some cases 
with apparently good results. The internal administration 
of calcium chloride, which increases the coagulability of the 
blood, has been employed. Hypodermoclysis, intravenous 
injection of saline solution and transfusion of blood have also 
been employed. 

Spontaneous hemorrhage is not so common in hemophiliacs 
as in those in whom the hemorrhagic diathesis exists in whom 
the coagulation time is not retarded and there is no retarda- 
tion of the clot. 

Coagulation Time of Blood. — The surgeon is at the present 
time able to cope successfully with massive hemorrhage from 
large vessels, by means of hemostatic forceps, ligatures or 
other means of controlling the loss of blood. Still, he is 
largely dependent upon the natural property of coagulation 
or clotting of the blood for stopping oozing from small vessels. 
When the blood is unable to clot, any wound, operative or 
accidental, is dangerous, as the oozing from capillaries and 
small vessels may continue until the person is exsanguinated. 

In the condition known as hemophilia the blood is not 
coagulable or only very feebly so. In long-continued jaun- 



298 MINOR SURGERY 

dice, purpura, scurvy, leukemia and certain diseases of the 
spleen, the coagulability of the blood may be much reduced. 
In such cases it is advisable to estimate the coagulation time 
of the blood prior to operation. This may be done roughly 
by picking up a number of drops of blood upon a glass slide, 
and estimating the time necessary for coagulation, either by 
tilting the slide and noting when it no longer sags under the 
influence of gravity, or by drawing a bristle through it at 
intervals to demonstrate the formation of the fibrinous clot. 
Ordinarily clotting should occur in two to five minutes. 

Wright's tubes are capillary tubes of uniform caliber, into 
which the blood may be drawn as far as a certain indicated 
point. A number of the tubes are filled and at intervals 
their contents are discharged, enabling one to note whether 
coagulation has as yet occurred. 

The Brodie-Russell-Boggs coagulometer is probably the 
most uniform and accurate in its results. In this method a 
drop of blood is picked up on the small end of a truncated 
glass cone. This drop is placed in the cell of the instrument 
and observed under the microscope. By means of a bulb a 
fine current of air can be directed against the hanging drop 
of blood. While the blood is still fluid, the red blood cells 
are agitated and dispersed by the air current, but when 
coagulation occurs the cells remain in their respective places, 
swinging back and forth as the current is played upon them 
as though they were embedded in an elastic jelly. So deli- 
cate and complex are the factors involved in the coagulation 
of the blood that all methods yet devised lack uniformity in 
their results and are not entirely trustworthy for clinical 
purposes. 

TREATMENT OF ABSCESS. 

In operations for evacuation of the contents of abscesses 
care should be taken to observe every precaution to prevent 
a new infection of the wound or abscess cavity; the skin over 
the abscess should be carefully cleaned to make it aseptic, the 
hands of the surgeon and the instruments to be brought in 
contact with it should also be aseptic. These precautions 
should be especially observed in the opening of chronic 



TREATMENT OF ABSCESS 299 

abscesses when a new variety of infection is liable to be intro- 
duced if aseptic precautions are not rigidly observed. If the 
pus is not definitely localized the application of hot fomen- 
tations contributes to the comfort of the patient; gauze satu- 
rated with hot boric solution and covered with rubber tissue 
and cotton, to retain the heat and moisture, is a good dressing. 

Acute Abscess. — This variety of abscess should be opened 
by incision, and this is best done with a straight, narrow, 
sharp-pointed bistoury. The incision should be deep enough 
to expose freely the cavity of the abscess, and should be 
parallel with and not across important structures, and it 
should also be made at as dependent a portion as possible. 
Abscesses of the limbs are opened by a longitudinal incision, 
and those in the region of the anus and breast by an incision 
radiating from the anus or nipple. 

In incising abscesses of the face and neck due regard should 
he had for the resulting scars; the incisions should be in the 
natural folds of the skin and abscesses of the neck and jaws 
should, if possible, be opened through the mucous membrane 
of the mouth. 

Pressure should not be made upon the walls of the abscess 
to empty it, as by so doing delicate vessels may be ruptured 
and cause hemorrhage, and the spread of the infection may 
be facilitated. 

The cavity of the abscess having been emptied of pus, it 
may be irrigated with normal salt solution' or the irrigation 
of the cavity may be omitted, and if the cavity is not very 
large or deep no drainage tube need be introduced, and a 
small piece of rubber tissue may be placed between the lips 
of the wound to prevent their adhesion; but if, on the other 
hand, the cavity is extensive and deeply situated, a rubber 
drainage tube or a strip of moist iodoform or sterilized gauze 
should be introduced to the bottom of the cavity to secure 
free drainage, and if a tube be used it should be fixed at the 
surface of the skin by a safety-pin. A gauze dressing, con- 
sisting of a number of layers, which has been moistened in 
boric or bichloride solution, is next placed over the wound, 
and is covered by a number of layers of dry gauze, which are 
in turn covered by a piece of rubber tissue. The latter may 



300 MINOR SURGERY 

be substituted by a few layers of sterilized gauze and cotton, 
and the dressing is finally secured by a roller bandage. The 
dressing is removed at the end of two or three days, the 
cavity being washed out with a mild antiseptic or saline solu- 
tion, or the irrigation may be omitted. The drainage tube may 
then be shortened or removed, and the dressings reapplied, 
as at the primary dressing. Under this method of treatment 
acute abscesses usually heal promptly. 

When there is extensive burrowing of pus it is advisable 
to make several incisions rather than one long incision and 
drain through each incision. Acute abscesses of the neck if 
under the deep fascia demand early incision; they may bur- 
row extensively or cause pressure upon important structures. 
Retropharyngeal abscess may interfere with the breathing 
and deglutition, and if it ruptures may cause suffocation; 
it therefore demands early opening. Ischiorectal abscess, 
from its tendency to open into the rectum and give rise to 
fistula, should be treated by early incision. 

Hilton's Method. — In deep-seated abscesses in the region of 
important structures the method of opening suggested by Mr. 
Hilton may be employed with advantage; it consists in mak- 
ing a small incision through the skin and cellular tissue; a 
director is next pushed through the tissues into the abscess 
cavity, which will be shown to have been reached by the 
escape of pus along the director; a dressing forceps with the 
blades closed is now pushed along the director into the abscess 
cavity, and when this has been accomplished the director is 
withdrawn and the forceps removed with the blades expanded 
so as to dilate the wound and allow the pus to escape. 

Tuberculous or Chronic Abscess. — This variety of abscess 
occurs chiefly in connection with tuberculous disease of the 
bones or joints. This variety of abscess contains the degen- 
erated products of tuberculous inflammation and true pus is 
only present when there has been an accidental infection with 
pyogenic organisms. It may be opened in various ways, the 
time at which this should be done depending upon the size 
and situation of the abscess and the amount of constitu- 
tional and local disturbance which the patient experiences 
from its presence. 



TREATMENT OF ABSCESS 301 

Aspiration. — A tuberculous abscess may be evacuated by 
means of the aspirator; the pus being withdrawn as far as 
possible, the puncture is sealed with a small piece of gauze 
covered with collodion. Reaccumulation of pus often takes 
place, and the aspiration has to be repeated a number of 
times. The greatest difficulty in the successful removal of 
the contents of tuberculous abscesses by means of aspiration 
is the presence of cheesy masses in the pus, which occlude the 
cannula and often prevent complete emptying of the cavity. 
This may be overcome by irrigating the cavity through the 
cannula with saline solution. 

Puncture and Injection. — This variety of abscess may also 
be evacuated by making a puncture through the skin and 
overlying tissues with a narrow bistoury, the surface having 
been previously sterilized with tincture of iodine; a director 
is next pushed through this small wound into the cavity of 
the abscess, and the pus is allowed to escape by stretching 
the wound with the director; when the cavity is emptied of 
pus it is washed out with saline solution or sterile water intro- 
duced into it by pushing the nozzle of a syringe into the 
cavity, and this is allowed to escape in the same way as the 
pus previously did. When all the irrigating solution has 
escaped the cavity may be injected with an emulsion com- 
posed of iodoform, 1 part, glycerin or sterilized olive oil, 10 
parts; after this has been introduced the small wound is 
closed by a compress of antiseptic gauze held in place by 
collodion, a bandage or by strips of adhesive plaster. This 
procedure has to be repeated several times before a tubercu- 
lous abscess is cured. After each operation it is found that 
the cavity of the abscess is diminished in size. A cure 
depends upon the death of the tubercle bacilli or healing of 
the causative focus. 

In evacuating tuberculous abscesses by means of the aspi- 
rator or by a small puncture there is absence of shock, and 
the loss of blood is insignificant, so that these procedures 
should generally be first employed, and the more radical 
operation of incision and curetting of the cavity of the 
abscess, which is accompanied with a certain amount of 
shock and hemorrhage, should be reserved for those cases in 



302 MINOR SURGERY 

which the less severe operations have not been followed by a 
satisfactory result. 

Incision. — Tuberculous abscesses are also treated by making 
a free incision into the abscess cavity with full antiseptic pre- 
cautions, and after the escape of the purulent matter the 
walls of the abscess should be thoroughly scraped with a 
curette; after the cavity has been freely washed out with a 
carbolic or bichloride solution or sterile water, large drainage 
tubes are introduced and an antiseptic dressing is applied to 
the wound. The edges of the incision may be brought 
together by sutures without the introduction of drainage, or 
the cavity may be packed with iodoform gauze and allowed 
to heal by granulation. The dressings are removed as soon 
as they become soaked, and the drainage tubes are shortened 
or removed as the discharge diminishes and the cavity 
contracts. 

Diffuse Suppuration. — This form of suppuration is treated 
by numerous punctures or incisions which allow the purulent 
matter to escape ; and where sloughs are present free incisions 
may be required to give exit to the necrosed tissues; the 
introduction of the drainage tubes may also be required. 
The wounds and the cavities, as far as possible, should be 
washed out with sterile water or bichloride solution and an 
antiseptic gauze dressing applied. The Carrel-Dakin treat- 
ment is of great value in this variety of suppuration. 

Sinus and Fistula. — These are suppurating tracts which 
result from abscesses or wounds. A sinus has only one orifice 
as its other extremity ends in the former abscess cavity. A 
fistula is a suppurating tract with two or more orifices which 
may be external or internal. A sinus or fistula may be kept 
from healing by the presence of a foreign body as is seen in 
sinuses in connection with necrosed bone, or by muscular 
action as is the case of fistula-in-ano or by the constant 
passage of the secretions of the part through the abnormal 
opening as in fecal, salivary or urinary fistula?. 

Treatment. — Foreign bodies should be removed, and in the 
case of fistula kept up by secretions from internal organs, 
the opening into the organ must be exposed and closed. If 



TREATMENT OF ABSCESS 303 

superficial they should be laid open freely and their surfaces 
scraped with a curette, and then lightly packed with strips 
of iodoform gauze and covered by an antiseptic dressing. 
Sinuses in accessible positions may be treated by dissecting 
out the walls of the sinus and closing the deeper parts of the 
wound with buried absorbable sutures, and suture of the 
superficial parts and the skin. If they are too deep to be 
treated by incision, their healing may be facilitated by the 
injection of stimulating solutions introduced by means of a 
syringe; the employment of solutions of chloride of zinc, 
nitrate of silver and sulphate of copper, varying in strength 
from 5 to 20 grains to the ounce of water, will often prove 
satisfactory. 

Beck's Bismuth Emulsion has recently been used with 
good results in the treatment of deep sinuses and fistulous 
tracts. Two different emulsions are employed known as No. 
1 and No. 2. No. 1 consists of bismuthi subnit, 30 gm., vase- 
line, 60 gm. No. 2 consists of bismuthi subnit., 30 gm., white 
wax, 5 gm., liquid paraffine, 5 gm., vaseline, 60 gm. These 
should be mixed while boiling. 

No. 1 emulsion is not so consistent as No. 2, and is used in 
superficial sinuses and is apt to escape from the sinuses in a 
short time, while No. 2 emulsion becomes more firm upon 
cooling and may remain in the tissues for a long time, and 
healing may occur with the emulsion in the tissues. 

These emulsions should be warmed in hot water until they 
become liquid and they can then be injected into the sinuses 
or fistulous tracts with a syringe, and soon become consoli- 
dated at the temperature of the body. They seem to exert 
a stimulating action on the walls of the sinuses favoring the 
growth of granulations and healing. These injections are 
also very useful in showing the depth and extent of sinuses 
connected with diseases of the bones and joints when after 
the injection of the emulsion, and roentgen-ray examina- 
tion will show the location in which the emulsion has been 
deposited. 

Cases of bismuth poisoning and death have been reported 
for the use of this emulsion. 



304 MINOR SURGERY 

SHOCK. 

This is a condition of physical depression or prostration 
which develops after severe injuries or operations, or pro- 
found emotion acting on the nerve centers. It is one of the 
most serious conditions which falls to the lot of the surgeon. 
No theory of shock is entirely satisfactory. The theory 
generally accepted is that there is exhaustion or inhibition of 
the vasomotor mechanism. Overstimulation or irritation of 
sensory nerves causes violent impressions to be conveyed to 
the nerve centers, which result in exhaustion or inhibition 
of the vasomotor centers, producing vasomotor paralysis. 
The peripheral arteries and capillaries are paralyzed and 
nearly emptied of blood, and the blood is largely transferred 
to the veins, especially to those of the splanchnic area, at 
the same time cardiac action is impaired, the blood-pressure 
is lowered and respiratory action is impeded. It has 
recently been shown that in many cases of severe shock 
acidosis is present. 

Crile believes that in shock there are demonstrable changes 
in the brain cells. He considers the most important causes 
of shock, fear, pain and traction, and that by eliminating 
these factors shock may be prevented or diminished. Fear, 
he holds, can be prevented by keeping the patient away from 
frightful influences and benumbing the association functions 
of the brain by the use of morphine and scopolamine. Nerve 
impulses may be blocked by infiltrating their trunks with an 
anesthetic such as novocaine. He uses a local anesthetic if 
possible, infiltrating the tissues with novocaine. If a general 
anesthetic is required he employs nitrous oxide rather than 
ether, as he considers it much less depressing. The term 
" anoci-association" is applied to this blunting of harmful 
association impulses. 

Physiological Block. — Infiltration of the nerves with novo- 
caine or eucaine, well above the area of operation, prevents 
the ascent of peripheral impressions so as to prevent shock. 
The use of morphine and scopolamine before operation also 
eliminates or diminishes shock. Nerve blocking is one of 
the most valuable procedures in modern surgery. 



SHOCK 305 

Shock may develop immediately upon or some time after 
the reception of the injury. Every traumatism is probably 
followed by a certain amount of shock, and, as a rule, its 
degree is proportionate to the severity of the injury received. 
Yet this rule is not without exception; certain classes of 
injuries are attended with marked shock, and the part of the 
body sustaining the injury will have an important influence 
upon the degree of development of shock. Contusions of the 
viscera, wounds of the testicle, contused and lacerated wounds 
of the trunk and extremities, if extensive and accompanied 
by free hemorrhage, are usually followed by marked and 
often fatal shock. Gunshot wounds causing perforation of 
important cavities of the body, injuries of the viscera, and 
shattering of the bones are also well recognized as giving rise 
to shock in a marked degree. Burns and scalds, if they 
involve a considerable surface of the body, are attended with 
severe shock. 

Diagnosis. — The condition of shock resulting from purely 
emotional causes is usually not profound or prolonged, and 
can be differentiated from that resulting from corporeal inju- 
ries by the history of the case. The condition arising from 
excessive hemorrhage presents many symptoms common to 
shock, but here the nature of the injury will often assist in 
the diagnosis, and in doubtful cases examination of the blood 
may be of service, for if such an examination shows that the 
red blood cells are considerably diminished, being 3,500,000 
or less, it is probable that the condition is due to hemorrhage 
rather than shock. Fat embolism may also be confounded 
with shock, but it should be remembered in differentiating 
the conditions that shock usually appears promptly, and the 
symptoms of fat embolism from thirty-six hours to three 
days after the injury. 

Symptoms. — A patient suffering from shock presents pallor 
of the surface, paleness of the lips, dilated pupils, clammy 
moisture of the skin, muscular debility, occasionally relaxa- 
tion of the sphincters, frequent, feeble, irregular pulse, sub- 
normal temperature and feeble, short, sighing respiration; in 
many cases extreme thirst is a prominent symptom. Exami- 
nation will show a marked fall in the blood-pressure. The 
20 



306 MINOR SURGERY 

senses are often perfectly retained. The temperature is 
always subnormal, and may vary from a point a little below 
the normal to a point below 90° F. (32° C). A depression 
below 97° F. (36° C), if it persists for a few hours, usually 
indicates a grave condition of shock, and reaction may not 
occur, although it has been observed in cases where the 
temperature was as low as 90° F. (32° C). 

Prophylaxis. — Unfortunately, many of the worst cases of 
shock are due to accidents, and here treatment can be directed 
only to the condition of shock itself; but the surgeon is often 
able to diminish to some extent the amount of shock following 
operations by judicious prophylactic treatment. In patients 
in whom shock is apt to be markedly developed, as in children 
or feeble or aged subjects, or in certain classes of operations, 
he may give stimulants before the operation, and see that 
the surface of the body is not unnecessarily exposed to chilling 
during the operation, that the operation is not needlessly 
prolonged, and that as little blood as possible is lost during 
its performance. 

In anemic or exhausted subjects blood transfusion a few 
days before operation will often be followed by the best 
results. 

Choice of the anesthetic is most important. Local anes- 
thesia may be used in adults in suitable cases, but is not often 
satisfactory in children. Nitrous oxide, alone, or combined 
with oxygen, should be preferred to ether. 

Shock developing during and after operations may be pre- 
vented or diminished if the operator is careful as to hemo- 
stasis, does not unnecessarily prolong the operation, avoids 
extensive and multiple incisions and excessive exposure and 
handling of the tissues; and he should bear in mind that 
shock in abdominal operations depends upon the length of 
exposure and the amount of traumatism of the peritoneum. 

The electrothermic mattress may be used with advantage, 
but care should be exercised in its employment, as serious 
burns have followed its use. The previous administration of 
an ounce of whiskey and the hypodermic injection of -£$ gr. 
of sulphate of strychnine, g^ gr. of sulphate of atropine, and 
the use of a small dose of morphine in feeble and aged 
patients will be followed by good results. 



SHOCK 307 

Treatment. — The first indication in the treatment of shock 
is to establish reaction. The patient should be covered with 
woolen blankets, the head should be kept low and dry heat 
should be applied to the surface of the body by means of 
hot-water bags, hot bottles or hot bricks; these should be 
wrapped in towels to prevent them from coming directly 
in contact with the surface; neglect of this precaution, which 
is most important if the patient is unconscious, often produces 
burns which may be followed by extensive sloughing. If the 
patient can swallow he should be given small quantities of 
whiskey or brandy, with 30-minim doses of aromatic spirit of 
ammonia, and, as absorption by the stomach is probably 
very slow in these cases, stimulants should be administered 
hypodermically; atropine is the most valuable stimulant that 
can be employed. From yj-g- to T |~g- gr. should, therefore, be 
injected and the injection repeated every hour or half hour 
until several doses have been given; it is especially indicated 
if there is profuse sweating. Caffeine citrate in doses of gr. 
ij may also be used with good results. Digitalin or cam- 
phorated oil may also be injected into the cellular tissues. 

Strychnine was formerly widely used in shock, but its use 
is not now considered of great value. A stimulating enema 
of whiskey and warm water may be employed. Morphine is 
the most useful drug in shock. From J to J gr. should be given 
and repeated if necessary to insure quiet and freedom from 
pain. A large enema of warm saline solution may also be 
employed. As patients often complain of urgent thirst it is 
well to let them take a little black coffee, but not large 
quantities of water; free indulgence in water does not seem 
to quench the thirst, and is apt to be followed by vomiting. 
In cases of prolonged shock, transfusion of blood may be 
employed with advantage. This is especially helpful if 
acidosis is present. Autotransfusion may be employed in 
this emergency. This consists in applying muslin or rubber 
bandages to the limbs to drive the blood to the vascular and 
nervous centers. Intravenous injection of saline solution, to 
which is added 1 dram of a 1 : 1000 adrenalin chloride solution, 
is likely to be of most service when the condition has been 
preceded by the loss of a large quantity of blood. Intra ven- 



308 MINOR SURGERY 

ous saline solution should be given slowly, and in not too 
large quantities, for it should be remembered that if given 
rapidly and in too large quantities it may accumulate in the 
cavities of the right heart and arrest its function. Subcu- 
taneous infusion (hypodermoclysis) of saline solution also has 
been employed with good results. Crile's method of centri- 
petal arterial transfusion may be practised. In this procedure 
a cannula is inserted into an artery toward the heart, and 
saline solution is introduced, 15 to 30 minims of a 1:1000 
adrenalin chloride solution is introduced in the rubber tube 
connected with the cannula by means of a hypodermic 
syringe. The injection should be made at intervals of a few 
minutes, introducing one or two minims at a time. 

DRESSING OF WOUNDS. 

Incised Wounds. — These wounds present the conditions 
favorable for prompt healing, and after sterilizing the sur- 
rounding skin they should first be carefully irrigated with 
saline solution or sterilized water to remove any blood clots 
or foreign bodies, or wiped with a sterilized gauze pledget; 
and after any hemorrhage which is present is controlled by 
the use of ligatures, if the wound be an extensive or deep 
one, provision should be made for drainage by introducing a 
drainage tube or a few strands of sterilized catgut at the 
bottom of the wound, allowing the ends to project from its 
most dependent portion. Irrigation of the wound with saline 
solution may be employed if there is reason to suppose the 
wound has been infected before coming under treatment. 
In superficial incised wounds after the hemorrhage has been 
controlled, it is not usually found necessary to make provi- 
sion for drainage. If drainage is considered necessary a 
narrow strip of rubber dam, a few strands of catgut or a 
drainage tube should be introduced to the depth of the 
wound. In closing wounds the surgeon aims to approximate 
the various tissues accurately, so that muscle comes in contact 
with muscle, fascia with fascia, etc. He also strives to see 
that no pockets (dead spaces) are left, in which blood or serum 
may accumulate, which will serve as a culture medium for 
germs. If the wound be a deep one, involving the muscles 



DRESSING OF WOUNDS 309 

and deep fascia, buried sutures of catgut or silk should be 
applied to approximate the muscles and fascia ; and if import- 
ant nerves or tendons have been divided their ends should 
be brought into apposition by sutures of catgut or sterilized 
silk. Wounds of nerves and tendons are more apt to be over- 
looked in incised wounds than in lacerated wounds when the 
exposure of the parts is greater. This seems especially the 
case for incised wounds of the hand and lower forearm. The 
superficial portions of the wound should next be brought 
together by the introduction of a number of interrupted 
sutures, catgut, silkworm gut, or silk being employed for this 
purpose. The accurate apposition of the edges of wounds of 
this variety is secured by the introduction of a number of 
sutures placed closely together. 

After a wound of this variety has been closed the subse- 
quent dressing is accomplished by covering the surface of the 
wound with a number of layers of sterilized gauze and a pad 
of sterilized cotton, which are held in place by a gauze 
bandage. Under this form of dressing prompt healing of 
incised wounds is the rule, and the wound need not be 
redressed for a week or ten days unless some indications exist 
for change of dressing at an earlier period. The wound may 
also be dressed by applying dichloramine-T over the wound 
and applying a dry sterile gauze dressing. If a drainage tube 
has been used it should be removed at the end of the second 
day, and the wound dressed with dry sterile gauze, and at the 
end of ten days the sutures should be removed. A sterilized 
gauze dressing is usually next applied, and allowed to remain 
for a few days longer. 

In superficial incised wounds involving only the skin and 
cellular tissue if limited in extent, after cleansing the wound 
and controlling the bleeding, the edges should be approxi- 
mated with sutures. The wound should then be covered 
with strips of sterilized gauze, over which is painted a mixture 
of: Tr. benzoin, 5j; collodion, 3vij. This forms a firm anti- 
septic scab which need not be removed until the wound has 
healed. 

Lacerated Wounds. — These present edges which are torn 
and not sharply cut and the vitality of the injured parts is 



310 MINOR SURGERY 

often so seriously impaired that prompt union in this variety 
of wounds is not, as a rule, to be looked for. Wounds of this 
nature should first be irrigated with saline solution, sterilized 
water, or a 1:4000 bichloride solution, and blood clots and 
foreign bodies removed. If the wounds be deep, drainage 
tubes should be introduced; on the other hand, if they be 
superficial, or if the edges are not closely approximated, pro- 
vision for drainage may be omitted. Extensive lacerated 
wounds are often accompanied by severe shock; in such cases 
nerve blocking may be used to arrest the shock producing 
impulses. The mechanical cleaning of the wound after this 
procedure can be accomplished with little discomfort to the 
patient. The torn or irregular edges of the wound should 
next be brought into apposition at a few points by the intro- 
duction of catgut or silkworm-gut sutures, applied not very 
closely together; and if the edges are discolored and their 
vitality seems markedly impaired it is better not to use 
sutures. If the edges of the wound are so much crushed that 
their vitality is destroyed they may be trimmed away with 
scissors until a surface possessing a fair vitality is secured. 
The removal of devitalized tissue and foreign bodies is practi- 
cally debridement of the wound which has recently been 
extensively practised in gunshot wounds. The evil results 
arising from the introduction of sutures into this variety of 
wounds, with the idea of closely approximating their edges, 
are so common that the surgeon who dispenses with the use 
of sutures entirely errs upon the safe side. The use of many 
sutures in wounds of this nature often causes marked tension, 
which is frequently followed by impairment of the vitality 
of the injured tissues, and sloughing results. The wound 
should next be dressed with sterilized gauze and cotton, or 
dichloramine-T may be applied to the surface of the wound 
and a sterilized gauze dressing laid over it. It should be 
dressed within twenty-four or thirty-six hours, and if it runs 
a favorable course it should be redressed at intervals of two 
or three days; the time required for repair of a wound of this 
nature is longer than that for an incised wound. 

In lacerated wounds of the extremities continuous irriga- 
tion of the wound by a warm antiseptic or saline solution, 



DRESSING OF WOUNDS 311 

applied as described (p. 133), is often followed by the most 
satisfactory results; wounds produced by machinery and 
railway accidents, .in which the vitality of the tissues is much 
impaired, are particularly suitable cases for this method of 
treatment, and here the same caution should be exercised as 
regards the introduction of sutures. 

Contused Wounds. — This variety of wounds possesses 
many characteristics in common with lacerated wounds : the 
edges are bruised and the injury of the subcutaneous tissue 
is often more extensive than the external wound would lead 
one to suspect. They are dressed in the same manner as 
lacerated wounds and the same objection here exists to the 
use of sutures as in the latter class of injuries. 

Punctured Wounds. — These wounds are inflicted by sharp- 
pointed instruments, and it may happen that a portion of the 
vulnerating body remains in the wound, as is frequently the 
case in wounds produced by needles, splinters of wood, metal 
or glass. Another complication in this variety of wound is 
the injury of vessels, giving rise to concealed hemorrhage, or 
of nerves, resulting in neuritis or neuralgia. Punctured 
wounds may also involve the viscera and joints. I have seen 
a case of punctured wound of the knee-joint by the prong of 
a table fork result in infection of the joint which required 
amputation of the thigh. Simple punctured wounds should 
be sterilized with iodine or dichloramine-T, and covered by a 
sterilized gauze dressing, and if no complication exists their 
healing is usually very rapid. 

Punctured wounds are apt to be infected and should not be 
closed by suture, so that discharges should have free exit. If 
a punctured wound shows signs of infection it should be freely 
opened and drained. 

A very serious form of punctured wounds arises from the 
impaling of a portion of the body by pieces of wood or metal, 
the part being transfixed or simply penetrated; the pene- 
trating object may break off, leaving a portion of it in the 
wound, or may retain its position in the body, so that it is 
difficult to separate the body from it. This accident usually 
results from persons falling upon sharp sticks, wooden or iron 
palings. 



312 MINOR SURGERY 

When a foreign body remains in the wound, as often hap- 
pens in punctured wounds produced by needles and splinters, 
the punctured wound should be converted into an incised 
wound, and the body should be searched for and removed; 
in doing this in the case of wounds of the extremities the 
operation is much facilitated by the employment of Esmarch's 
bandage. The roentgen or axrays may be employed with 
advantage in locating foreign bodies, such as pieces of glass or 
metal, in punctured wounds. After the removal of the 
foreign body the wound is treated as an incised wound, and 
an antiseptic or aseptic gauze dressing should be applied. 
When concealed hemorrhage occurs after a punctured wound, 
the wound should be laid open and the bleeding vessel 
searched for and ligated if possible, and the wound should 
afterward be dressed as an incised wound. 

Tetanus frequently develops in lacerated and punctured 
wounds, the infection occurring at the time of their infliction, 
especially if soiled by earth. Wounds received by those 
working in horse stables are prone to this variety of infection. 
For this reason many surgeons advise that an immunizing 
dose of antitetanic serum be given in all these wounds. 

Stab Wounds.— These wounds are caused by sharp-pointed 
cutting instruments, such as a dagger, knife, scissors, bayo- 
net or sword, and partake of the nature of both incised and 
punctured wounds. They may be dangerous injuries from 
implication of the joints, bloodvessels, nerves and the thor- 
acic or abdominal viscera. The skull may be penetrated and 
the brain involved. Stab wounds of the neck are dangerous 
and often rapidly fatal from hemorrhage. Hemorrhage and 
shock are prominent symptoms of these injuries. If the 
wound does not involve the great cavities of the body or im- 
portant bloodvessels or nerves the wound should be treated 
as an incised wound. If large bloodvessels are injured the 
wound should be enlarged, the vessel exposed and ligated; 
if nerves have been divided they should be sutured. Pene- 
trating stab wounds of the chest, abdomen and skull should 
receive appropriate treatment. 

Poisoned Wounds. — These wounds are caused by the 
absorption, by means of a cut or abrasion in the skin, or by 



DRESSING OF WOUNDS 313 

the sweat or sebaceous glands, of irritating or infected material 
from a dead body in making dissections or postmortem exami- 
nations, or in operating upon living subjects, and often result 
in serious consequences. Infection occurring from a living 
subject in operating is apt to give rise to a similar specific in- 
fection, or a mixed infection may result; whereas infection 
occurring from dead bodies is usually caused by the bacteria of 
putrefaction, as infective microorganisms retain their virulence 
for only a short time after death. Such wounds, as soon as pos- 
sible after their reception, should be carefully washed out with 
a solution of bichloride of mercury, 1 : 2000, and the surface 
touched with a 30-grain solution of chloride of zinc, and then 
dressed with an antiseptic dressing. If, however, this pre- 
caution is not taken, or the wound has escaped notice, and in 
a few hours becomes inflamed and painful, and evidences of 
lymphatic involvement show themselves, the wound should 
be opened and its surface should be thoroughly sponged with 
a 2 per cent solution of formalin or with a 30-grain solution 
of chloride of zinc, and finally with a saline solution, and it 
should then be dressed with a moist antiseptic gauze dressing. 
Dichloramine-T, or the instillation of Dakin's solution, may 
also be used. Under these methods of dressing, the poisoned 
wound is often converted into a healthy one, even after the 
lymphatic involvement is well marked, and it usually heals 
promptly without further constitutional disturbance. If the 
infection spreads and the constitutional disturbance increases, 
free incisions into the surrounding tissue will be required to 
relieve tension and permit of the escape of serum or pus. 

Scalp Wounds. — The scalp is very vascular and wounds 
bleed profusely, by reason of the fact that many of the vessels 
are in fibrous tissue and cannot contract and retract. Incised, 
lacerated and contused wounds are very common. Sloughing 
in scalp wounds is rare, by reason of its great vascularity. 
Extensive flaps loosened in lacerated wounds, having only a 
narrow pedicle, usually retain their vitality. Hemorrhage, 
unless arising from a large vessel, can usually be controlled 
by pressure as the firm bony base makes this very effective. 
Extensive separation of the edges of the wound does not 
occur in scalp wounds. In wounds of the scalp penetrating 



314 MINOR SURGERY 

the occipito-frontalis, if infection occurs pus burrows freely 
under this muscle. 

Treatment. — The scalp in the region of the wound should be 
shaved, and the skin sterilized with alcohol, tr. iodine or picric 
acid solution, and after the bleeding has been controlled the 
edges of the wound should be approximated with sutures of 
silk, catgut or silkworm gut. A sterile gauze dressing is next 
applied and held in position with a bandage. "The wound 
may be covered by strips of gauze held in place by tincture of 
benzoin and collodion. Deep infected scalp wounds with 
abscess require numerous openings made at dependent parts 
of the scalp. 

Contusions of the scalp are accompanied by marked swelling 
due to hemorrhage. Hematoma of the scalp, which often 
presents a central depression, may be confounded with 
depressed fracture, but in hematoma examination reveals 
bone on a level with the surrounding skull and the edges of the 
depression are smooth and circular and slightly elevated 
above the surface of the bone. Treatment consists in the 
application of moist gauze dressing and pressure; the blood 
is usually absorbed rapidly, but if a collection of fluid blood 
remains after a reasonable time, incision for its evacuation 
may be required. If the hematoma becomes infected and 
pus forms prompt drainage should be secured by incision. 

Gunshot Wounds. — These in civil life result from projectiles 
from shotguns, rifles, revolvers and blank cartridges. The 
wounds resulting from gunshot missiles are of the nature of 
contused and lacerated wounds. The ball may penetrate the 
tissues, a cavity or organ, and lodge in which case it is known 
as a penetrating wound. If it enters and emerges it causes 
a perforating one; in the former there is a wound of entrance 
and in the latter there is in addition a wound of exit. The 
missile may carry into the tissues pieces of clothing and 
foreign matter which are certain to cause infection . The bullet 
of the sporting rifle is larger, softer, has no jacket, or only a 
partial jacket, and has less velocity than that of the army 
rifle, so that it is likely to lodge in the tissues rather than to 
perforate, and is more likely to be deflected and deformed. 
The ball may simply graze the surface and produce a brush- 



DRESSING OF WOUNDS 315 

burn or contusion of the skin or a gutter; or may penetrate 
the tissues, injuring the bloodvessels, nerves, joints and bones, 
or penetrate the cavities of the body and wound the contained 
viscera. The principal symptoms of gunshot wounds are 
shock and hemorrhage; the latter may be profuse if a large 
vessel is injured; later, infection may develop. The bullet 
itself is not apt to be infected, and if this develops it is usually 
due to foreign matter carried into the tissues with the bullet. 

In gunshot wounds from the sporting rifle the bullet may 
perforate the tissues without injuring large bloodvessels and 
nerves, or may be deflected by bone or tendon, or be deformed 
by striking the bones, and cause widespread laceration of the 
tissues. Fracture of the bone may result from impact of the 
bullet. Bullets penetrating the abdomen or chest, with 
wounds of the viscera and of the skull, produce wounds 
which are generally fatal. Wounds of the joints are also 
grave injuries. Shotgun wounds from small shot at close 
range produce most serious injuries, the shot and wadding 
entering the tissues in a mass produce extensive laceration, 
and may tear away fingers or toes or portions of the hands 
and feet or of the extremities. I have seen avulsion of the 
arm from a shotgun wound at close range. If the charge is 
received at long range a number of shot may enter the body, 
but the wounds are, as a rule, not serious unless the eyeball 
is penetrated. 

Wounds from revolver or pistol balls are those most fre- 
quently seen in civil practice, and their gravity depends upon 
their location. Wounds of the great vessels and penetrating 
wounds of the joints, skull, abdomen and thorax are most 
serious injuries. A large number of these wounds seen in 
civil practice are suicidal, and usually involve the skull, 
thorax or abdomen. Shock and hemorrhage follow these 
wounds; the latter may be at first free but soon ceases unless 
large vessels have been injured. 

Blank-cartridge Wounds. — These result from the explosion 
of a fulminate used in toy pistols, and cause burns and lacera- 
tions of the skin, with at times portions of the clothing, or of 
the paper envelope of the cartridge being driven quite deeply 
into the tissues. Tetanus is a quite frequent complication of 
these wounds. 



316 MINOk SURGERY 

Treatment. — Shock is a prominent symptom in severe gun- 
shot wounds and demands appropriate treatment. The most 
important part of the treatment of these wounds is to pre- 
vent and control infection and not the removal of the bullet. 
Hemorrhage, if moderate, may be controlled by pressure; if 
profuse, temporary hemostasis should be secured by the use 
of a tourniquet or pressure, and the wounded vessel should 
be exposed by incision and ligated. In perforating wounds, 
which do not enter the great cavities of the body or injure 
important structures, the wound of entrance and exit should 
be swabbed with iodine and a sterilized gauze dressing 
applied. 

In uncomplicated penetrating wounds the wound should be 
swabbed with iodine and a sterile dressing applied. The posi- 
tion of the bullet should not be located by probing, but by a 
a roentgen-ray examination, or by the fluoroscope. The 
removal of the bullet should be accomplished if it is in an 
accessible location, or if there is reason to think infective 
matter has been introduced with it. Balls often become 
encysted and remain in the tissues for years without, causing 
any trouble. If it is found that foreign bodies have been 
introduced into the wound, and that the tissues have been 
more or less devitalized, debridement of the wound should 
be done, and Carrel-Dakin solution instilled, and primary, 
or delayed primary, suturing of the wound employed. In 
penetrating or perforating wounds involving the abdomen 
probing of the wound should not be done. The position of 
the ball may be located by roentgen-ray examination. In 
these wounds the intestines may be perforated in a number 
of places and the solid viscera involved. Visceral injuries 
are most serious. Laparotomy should be done as early as 
possible, and visceral injuries, if present, found and repaired. 
The results following laparotomy for gunshot wounds of the 
abdomen are generally very satisfactory. Wounds of the 
chest may be rapidly fatal if the heart and great vessels are 
involved. In wounds of the chest, the skin wounds should 
be sterilized, and a sterile occlusion dressing applied, and the 
ball should be located by roentgen-ray examination, and the 
question of its removal should be decided by the development 



DRESSING OF WOUNDS 317 

of symptoms. In wounds of the skull the question of removal 
of the ball should be decided by the roentgen-ray findings and 
the development of brain symptoms. 

Wounds from blank cartridges should be sterilized and 
foreign bodies removed, have dichloramine-T applied and a 
sterile dressing. The use of of an ti tetanic serum should be 
considered in all gunshot wounds. It was used as a routine 
treatment in such wounds during the late war, and should 
always be used in blank-cartridge wounds. 

Carrel-Dakin Treatment. — Dakin, as the result of experi- 
mental work, concluded that a solution of sodium hypo- 
chlorite free from caustic alkali and varying between 0.45 
per cent and 0.5 per cent, furnished an ideal antiseptic. 
Dakin's solution rapidly diminishes in strength when intro- 
duced into a wound and it is important to provide for its 
frequent renewal as well as a means of bringing it in contact 
with all parts of the wound, as it is difficult to sterilize one 
part of the wound while others remain septic. Carrel and 
Dakin devised a technic of wound treatment to accomplish 
this object, which has been widely and successfully employed. 
It requires special training to employ it efficiently. 

Material and Appliances Required. — 1. A solution of 
sodium hypochlorite prepared by the Dakin and Daufresne 
method. 

2. A glass container holding 500 to 1000 cc. 

3. Two yards of moderate sized rubber tubing. 

4. Adjustable clamp to control the flow of the solution 
through the rubber tube. 

5. Rubber instillation tubes about 25 cm. long of different 
diameters, the average being 16 to 18 French scale. The 
tubes are closed by tying at one extremity and are perforated 
with small holes by a punch for their lower two- thirds. The 
primary and secondary tubes are 7 mm. in internal diameter, 
the final distributing tubes are 4 mm. and the holes in these 
tubes are only 1 mm. (^ inch) in diameter. 

6. Ordinary rubber drainage tubes 25 to 35 cm. long with- 
out lateral holes. 

7. Glass collecting and distributing tubes. 

8. Dressings consisting of pads of different sizes made of 



318 



MINOR SURGERY 



cotton surrounded by gauze, a layer of absorbent cotton, next 
a thicker layer of non-absorbent cotton. These are held 
together by the surrounding layer of gauze secured by a few 
stitches. These pads should be about 3 cm. in thickness and 
should be of three sizes, one large enough for the thigh or leg, 
another to surround the arm and a third of smaller size. 
Webbing straps with buckles to fasten the dressing in place. 
9. Sterilized strips of gauze saturated with yellow petro- 
latum for protection of the skin. 

Fig. 242. 




Instillation apparatus for Carrel-Dakin treatment. 



To obtain satisfactory results by the Carrel-Dakin treat- 
ment the technic should be observed accurately. This treat- 
ment is applicable not only to wounds received in war, but 
also to those seen in civil practice, such as compound fractures 
and dislocation, lacerated, contused, punctured and infected 
wounds. The first requisite in the treatment of the wound is 
its mechanical sterilization to prepare it for chemical steriliza- 
tion. The wound or infected tissues should be painted with 
tincture of iodine, and the cavities of the wound fully exposed 
by incisions if necessary. Bruised skin or tissue is likely t 



DRESSING OF WOUNDS 319 

become necrotic and should be removed with scissors or the 
knife. Foreign bodies, such as pieces of clothing, fragments 
of metal, stone, wood or detached fragment of bone should 
be removed. All non-infected tissues should be carefully 
preserved. The object of this mechanical cleansing of the 
wound, debridement, is to remove everything that has been 
infected by the traumatism or is likely to be infected later. 
The same careful mechanical cleansing should be practised 
in the case of wounds. Comminuted fragments of bone 
should not be removed unless detached. Great care should 
be taken to secure complete hemostasis before the introduc- 
tion of Dakin's solution, which has the power of dissolving 
recent blood clots, which may cause secondary hemorrhage if 
vessels are not properly secured by ligatures. The fingers 
and hands, even if covered by rubber gloves, should be 
brought in contact with the wound as little as possible. 
Sterilized instruments should be used in the manipulations 
and in handling the dressings. 

The tubes should be so placed in the wound that the fluid 
will come in contact with all parts of the wound. The placing 
of the tubes will therefore vary with the nature of the wound, 
in superficial wounds a layer of gauze is applied and the tubes 
laid upon this and covered by another layer of gauze and the 
pad. In penetrating wounds the tube is introduced to the 
depth of the cavity and the solution is allowed to well up 
from the bottom. In wounds of this variety, with cavities 
at the depth, or those in which the point of entrance is on the 
posterior surface of the body or extremities, a wrapping of 
gauze may be securely fastened to the tube which becomes 
saturated with the solution and brings it in contact with the 
walls of the cavity. In perforating wounds the tube is passed 
from the lower to the upper opening and the liquid escaping 
from the orifices in the tube flows back alongside of the tube 
to the inferior opening. Wounds of the hands and feet may 
be immersed in the Dakin solution for ten to fifteen minutes 
every two hours. Instillation of the fluid is made every two 
hours day and night by releasing the clamp for a few seconds. 
The instillation of fluid is not done with the object of irriga- 
ting the wound — merely to keep the wound surface moistened 



320 MINOR SURGERY 

with the solution. For the average wound 10 cc is sufficient. 
Every day the dressings should be removed and the wound 
inspected and flushed to see if the solution is being properly 
delivered. It also serves. mechanically to wash away any 
excess of wound secretion. The average time required to 
sterilize a wound by this dressing is from five to ten days, but 
in compound fractures and badly traumatized wounds, a 
much longer time may be required. The sterility of the 
wound is proved by a bacteriological test. 

Systemic bacteriological examination of the wound is made 
every second day to determine the number of microbes upon 
the wound surface. A standard loop is used to carry a por- 
tion of the secretion to a microscopic slide, and the number of 
microbes is counted in the microscopic field, and the results 
are entered upon a suitable chart. When the microbes are 
absent from the wound in three successive counts the wound 
is considered sterile. The bacteriological examination should 
be made one or two days after the treatment has been started 
and repeated at intervals of one or two days until the wound 
is sterile. If the details of treatment are neglected or stopped 
prompt reinfection of the wound is liable to occur. When the 
wound is sterile it is often possible to close it by sutures and 
secure prompt healing. If the wound is not one for suturing 
it may be diminished in size and the time of healing much 
shortened by making elastic traction upon the edges and sur- 
rounding tissues by painting the surrounding tissues with 
Heusner's glue and fastening canton-flannel bands, which 
have short hooks inserted at every 2 cm., to the tissues by 
this glue. When the canton-flannel bands are firmly adher- 
ent to the skin rubber bands are attached to the hooks or a 
rubber lacing applied which draws the edges of the wound 
together. 

Debridement of Wounds. — This procedure, which consists of 
the mechanical cleansing of wounds, the removal of foreign 
bodies and devitalized or partially devitalized tissues, has 
been employed for years in the treatment of lacerated and 
infected wounds, but was developed into a definite technic in 
the treatment of gunshot wounds in the recent war. It was 
employed in all war wounds soiled and likely to develop sub- 



DRESSING OF WOUNDS 321 

sequent infection. It was always practised in shell wounds 
and in bullet wounds where the tissues were tense and painful, 
and almost always in the case of lodgment of the bullet. 

Ashhurst describes the debridement of a gunshot wound as 
follows : " The wound of entrance and exit are widely opened 
by incisions, when possible in the longitudinal axis of the limb 
and parallel to the main muscular masses. These debride- 
ments are frequently 25 to 30 cm. (10 to 15 inches) in length, 
the usual error being to make them too small. The wound 
area being thus slit open freely to view, the next step is exci- 
sion: (1) The devitalized skin immediately surrounding the 
wounds is cut away (no more than is absolutely devitalized 
should be sacrificed) ; and (2) the entire mass of contused and 
lacerated subcutaneous tissues and muscle is cut bodily away 
with scissors. Accurate anatomical knowledge is required to 
avoid damage to important bloodvessels and nerves. All 
devitalized and hemorrhagically infiltrated muscle must be 
excised although it may not be actually invaded by bacteria 
at the time of operation (and probably is not until eight to 
twelve hours have elapsed since the injury), yet if left, it is 
certain to become infected. The surgeon should proceed 
methodically, excising piecemeal these tissues until he reaches 
muscle, which when cut reacts promptly by contraction. 
Usually in the course of debridement and excision, he comes 
upon shell fragments and other foreign bodies (fragments of 
clothing, mud, wood, etc.), and at once does extraction which 
is the third stage of the operation. In exceptional cases the 
missile enters without causing much laceration and its track 
has to be followed by dissection, layer by layer, until the 
missile is found. When the tract can no longer be followed 
by the eye it is justifiable to insert the finger for palpation. 
Usually if the missile is less than 0.5 cm. in diameter it is use- 
less to make prolonged search for it, the missile itself being 
comparatively harmless after removal of the tissues liable to 
infection. Frequently the missile can be extracted more 
easily by counter-incision than through the wound of entrance. 
Finally, hemostasis must be secured and all complications 
(fractures, severed bloodvessels, tendons and nerves) should 
receive appropriate treatment, 
21 



322 MINOR SURGERY 

"Drainage is very important. Slow healing of wounds is 
due to pocketing of infection, and this can only be prevented 
by dependent drainage. A counter-incision made for extrac- 
tion may be used for drainage, but if not suitably situated 
for dependent drainage, another counter-incision should be 
made where indicated. It should be amply large and a 
rubber tube (1 to 1.5 cm. in diameter) should then be passed 
from one wound to the other; unless this tube passes easily 
through the wound without any bending whatsoever, the 
wound should be more widely opened. The entire wound 
surfaces are then swabbed with iodine (3 per cent), flavine 
(1 to 2000), picric acid (2 per cent) or Menciere's solution. 
If nothing else is available ether alone may be used, but this 
as well as Menciere's solution is apt to increase oozing of the 
blood. 

"Dressing the Wound. — If debridement has been adequately 
done, and all devitalized tissues have been excised, it is then 
sufficient to provide a sewer (rubber tube) which will carry 
off the unavoidable wound secretions, which if dammed up in 
puddles would encourage the growth of bacteria. When 
drainage is provided it is unnecessary and harmful to stuff 
the entire wound with gauze. Sterile gauze and cotton in 
abundant quantities should be applied to the wound surfaces 
of the wound area and securely bandaged in place. Fixation 
by splints is of great value for transportation, even in the 
absence of fracture. 

"Primary and Delayed Primary Suture. — If debridement is 
properly done within twelve or eighteen hours of injury, and 
the wounds are completely sutured (providing for drainage) 
at once, and if the patients are not evacuated but kept abso- 
lutely quiet about 85 per cent of such wounds will heal 
without further trouble; the remainder will require opening 
for infection. On the other hand, if these patients, after 
suturing the wounds, are evacuated at any time within a 
period of ten days or two weeks, at least 90 per cent of such 
wounds will break down or require to be opened for infection, 
and only 10 per cent will heal without further trouble. 
Hence the absolute rule that in periods of great activity, 
when immediate evacuation after operation is necessary, that 



DRESSING OF WOUNDS 323 

no wounds shall be sutured. But when these patients, after 
proper debridement, reach the bases where they may be kept 
permanently, delayed primary suture is very successful. If 
all wounds, not including bone, are sutured immediately upon 
arrival at the Base, approximately 85 per cent of such wounds 
will heal without difficulty, and only 15 per cent of them will 
require opening for infection. This is so, regardless of the 
number and kind of bacteria present in the wounds, with the 
exception of the streptococcus. Almost without exception, 
wounds infected by the streptococcus will require reopening; 
and if the presence of the streptococcus can be ascertained 
beforehand it will be useless to attempt suture. 

"Secondary Suture. — Many wounds, which have not been 
treated by primary or delayed primary suture, may be steril- 
ized while granulating, and then secondary suture will prove 
successful. The best method of chemical sterilization is by 
the Carrel-Dakin solution. It should not be overlooked that 
this is efficient only when the wounds are mechanically pre- 
pared in advance; this often requires a secondary operation 
(debridement, sequestrotomy) ; and as such operation in the 
presence of streptococcic infection frequently cause further 
spread of the infection, it can be readily understood how diffi- 
cult the sterilization of such a wound may prove. If such 
wounds continue to heal, even if slowly, it is best to pursue a 
conservative course. 

"To perform secondary suture it is usually sufficient to 
freshen the skin edges, undermining them if necessary, and to 
close the wound not too tightly by deep sutures. It is always 
important not to leave any dead spaces, and for this purpose 
buried sutures may be necessary, but their use, as well as that 
of drainage, should be avoided if possible." 

Powder Burns.— These result from. the explosion of gun- 
powder, and, in addition to the burning and laceration of the 
tissues, are accompanied by the introduction of grains of 
unburnt powder into the skin, which, if not removed, leave 
permanent points of pigmentation. These wounds should 
first be washed with a 1 : 2000 bichloride solution, and upon 
the face, to avoid unsightly pigmentation of the skin, care 
should be taken to pick out the small masses of powder with 



324 MINOR SURGERY 

a needle or the sharp point of a tenotomy knife. The surface 
should then be dressed with antiseptic gauze or with lint 
spread with an ointment of boric acid or an ointment of 
aristol, consisting of \ or 1 dram of aristol to 1 ounce of vase- 
line, this dressing being covered by a few layers of gauze and 
cotton, held in place by a roller bandage. 

In pigmented scars following powder burns the powder 
grains may be removed by electrolysis. 

Contusions or Bruises. — These wounds differ from con- 
tused wounds in the fact that the skin is not broken, although 
in spite of this fact there may exist very extensive laceration 
of the subcutaneous tissues, accompanied by more or less 
extravasation of blood from the injured vessels. When not 
sufficiently severe to require operative treatment they should 
be dressed by applying over them several layers of lint satu- 
rated with lead water and laudanum, and over this dressing is 
placed a layer of waxed paper or rubber tissue, and the dres- 
sing is secured by a roller bandage. A solution which I find 
most satisfactory in the dressing of contusions is as follows: 
ammonii chloridi, grs. xx; tr. opii et alcoholis, aa5j; aquae, 
§i. Several layers of lint saturated with this solution are 
laid over the contused tissues, and are covered with waxed 
paper, oiled silk or rubber tissue. 

Extensive collections of blood following contusions often 
remain in the tissues for some time if infection does not occur, 
and usually are absorbed. If this result does not follow, and 
a large collection of fluid blood remains in the tissues, infection 
occurs, and an abscess forms, the blood or pus should be 
removed by incision with full antiseptic precautions. 

Sunburn. — Prolonged exposure of the surface of the skin 
to the sun results in a marked erythema. This is painful, but 
not serious unless a large surface is involved. The condition 
is often spontaneously relieved in a short time by the applica- 
tiod of vaseline or tr. benzoin comp., or a lotion composed of 
calamine (5iij)> zmc oxide (5iij)> alcohol (Tfl,xxx) and water 
(S viij) promptly relieves the irritation. 

Brush-burn. — This is a form of contused and lacerated 
wound which is produced by violent friction applied to the 



DRESSING OF WOUNDS 325 

surface of the body, and is often caused by coming in contact 
with rapidly revolving wheels, or the belting of machinery, or 
by the body being rapidly propelled over an uneven surface, 
or by a rope being rapidly drawn through the closed hands. 
The injury may vary from a superficial abrasion to absolute 
destruction of the skin. The surface of the brush-burn should 
be cleansed by a stream of normal salt solution, sterilized 
water, or 1 : 2000 bichloride solution, and then dressed with 
dichloramine-T or a powder of acetanilid and boric acid, equal 
parts, and a sterilized gauze dressing applied ; if suppuration 
occurs a moist bichloride or acetate of aluminum dressing or 
boric acid ointment should be applied. 

Burns and Scalds. — These injuries result from the action 
of heat on the living tissues. It may be applied as dry heat, 
hot solids or flame, or may be moist, as in the case of hot 
liquids and steam. The former produces burns; the latter 
scalds. There is no pathological difference between burns and 
scalds. The differentiation of a burn from a scald may be 
made by observing that in the former the hairs on the surface 
of the body have been destroyed. Dupuytren classified 
burns according to the depth of involvement of the tissues. 
(1) Erythema of the skin; (2) dermatitis, with formation of 
vesicles; (3) partial destruction of the skin; (4) destruction of 
skin; (5) destruction of subcutaneous tissues and part of the 
muscles; (6) destruction of the whole substance of the muscles. 

Symptoms. — These are local and constitutional. The local 
symptoms are pain and inflammation, varying in intensity 
and degree according to the extent of tissue damage. The 
constitutional symptoms are shallow respiration, feeble pulse, 
subnormal temperature and shock; the latter is a prominent 
symptom in severe burns. 

Following a severe burn, in twenty-four to thirty-six hours 
there is elevation of the temperature and congestion of the 
tissues in the region of the burn, pain, internal congestion, 
suppression of urine, delirium, and in some cases convulsions. 
From the second to the eighth day there is marked inflamma- 
tion and sloughing of the injured tissues. There may be also 
duodenal inflammation and the development of duodenal 



326 MINOR SURGERY 

ulcer (Curling ulcer), the latter probably being toxic or em- 
bolic in origin. 

Burns and scalds, if extensive, have a high mortality and 
are the most serious injuries which come under the care of the 
surgeon. The gravity of burns and scalds depends upon 
their extent and depth, and also upon their situation. Super- 
ficial burns of large extent are more dangerous than deep 
burns of limited extent. A superficial burn involving one- 
half of the body is apt to be fatal. Burns of the extremities 
are less dangerous than those of the head, chest and abdomen. 
Shock is an early cause of death in severe burns; later, infec- 
tion and renal complications may also cause a fatal issue. 

Treatment. — If pain is a prominent symptom morphine 
should be administered and stimulants should be given if 
indicated. As the excretion of urine is apt to be scanty, 
water should be given freely by the mouth, or by hypo- 
dermoclysis or enteroclysis if not retained by the stomach. 
Liquid diet should be given. 

A great variety of dressings have at different times been 
employed in the treatment of burns, some of which are still 
employed; others have been discarded. The treatment of 
burns and scalds is the same. The recently introduced 
paraffine and dichlor amine -T dressings have furnished en- 
couraging results. The present attitude of surgeons as to 
the treatment of burns is well expressed by the statement of 
Fontleroy and Hogland, "That as burns differ widely in 
degree, character of tissue destruction, bacterial content and 
progress of healing, no one procedure as a local measure will 
prove equally valuable for all cases and all stages of burns." 

The clothing should be carefully removed and the surface 
of the burn irrigated with warm salt solution. The body 
temperature should be maintained by the application of 
hot-water bags and woolen blankets, or by placing a cradle 
over the body and covering it with blankets. Under this 
canopy a 32-candle power electric lamp should be introduced, 
which will maintain a temperature of 100° to 105° F. Blebs, 
if present, should be opened to evacuate the serum, but the 
epidermis should not be removed. Superficial burns, in 
which the effect of the heat has extended only to the super- 



DRESSING OF WOUNDS 327 

ficial layer of the skin, may be dressed with lint saturated 
with a solution of sodium carbonate (5 j) to water (§ j) . This 
dressing rapidly relieves the pain. A solution of acetate of 
aluminum (5 iij) and water (1 pint) may be employed. Strips 
of lint or gauze saturated with this solution are laid over the 
surface of the burn and renewed each day. This dressing is 
a satisfactory one in the early stages of burns. 

The open treatment of burns has also been employed. The 
surface of the burn is dusted with powdered boric acid or 
stearate of zinc, and exposed to the air. The use of active 
antiseptic agents, such as carbolic acid, iodoform or bichloride 
of mercury, is not to be recommended, as their absorption 
may be followed by grave toxic symptoms. 

Continuous immersion of the burned surface in a warm 
bath has been employed in the treatment of burns with good 
results. 

Canon Oil. — This mixture, which is prepared by rubbing 
together equal parts of linseed oil and lime water until a 
thick creamy paste results, was formerly extensively used in 
the dressing of burns. Lint saturated with this mixture is 
placed over the surface of the burn. This dressing is a 
comfortable one to the patient in the early stages of burns, 
but possesses no antiseptic qualities and soon becomes 
offensive and requires frequent renewals. 

Salt Solution Dressing. — The surface of the burn is irri- 
gated with normal salt solution; sloughs are removed and the 
surface is covered with strips of sterilized rubber tissue 2 
inches in width. The strips should be so placed that there is 
a gap between the edges of each strip. Sterilized gauze is 
wrung out of warm salt solution and placed over the strips 
and held in place by a bandage. The gauze should be 
replaced as soon as it becomes saturated with the discharge 
which escapes between the edges of the strips. Fresh 
gauze should be applied without removing the strips, which 
renders the dressing much more comfortable to the patient. 

Picric Acid Dressing. — Picric acid solution has been very 
extensively used in the treatment of burns and scalds. This 
dressing should not be used in extensive burns or those 
which involve the tissues deeply or in burns in infants and 



328 MINOR SURGERY 

children who seem more susceptible to the action of this 
drug, as poisoning may result. After the surface has been 
cleaned and blebs have been opened, strips of sterilized lint 
or gauze are soaked in the solution and applied to the surface 
and covered with a layer of dry absorbent cotton, and the 
dressing is held in place by a bandage. The dressing soon 
dries and may be left in place for several days, when it is 
reapplied in the same manner. This application relieves pain 
and seems to diminish suppuration and leaves a healthy scar. 
The solution employed is as follows: Picric acid, gr. lxxv; 
alcohol, Biiss; aqua? dest., Oij. An ointment of picric acid 
(5ss) to 1 ounce of vaseline is also employed. 

White-lead Dressing. — This application, which consists of 
white lead (§ viij), powdered acacia (§ij), sodium bicarbonate 
(5j) and linseed oil (a sufficient quantity to make a mixture 
of the consistency of thick cream) is extensively used in the 
coal regions of Pennsylvania, where severe burns are very 
frequent. It is spread upon lint or gauze and applied to the 
burned surfaces; it does not require frequent renewal, and 
repair of the injured surfaces is rapid under its use. 

Paraffine and Ambrine Dressing. — Within a few years 
the dressing of burns with paraffine has been extensively 
employed with satisfactory results. Paraffine with 5 per 
cent of oil of amber, or a preparation of paraffine under the 
trade name of "Ambrine," the composition of which has 
not been given to the profession, may be employed. A paraf- 
fine preparation recommended by Hull, consisting of resorcin, 
1 part, oleum eucalypti, 2 parts, olive oil, 5 parts, soft par- 
affine, 25 parts, and hard paraffine, 65 parts, is probably one 
of the best paraffine combinations for the treatment of burns. 
In preparing this dressing the hard paraffine is melted, and 
the soft paraffine and olive oil added. The resorcin, dissolved 
in 95 per cent alcohol, is next added, or beta-napthol may be 
substituted for the resorcin; and finally oil of eucalyptus is 
added. The burned surface should be washed with salt solu- 
tion, all blisters should be opened and the surface dried by 
fanning or by means of an electric blower. The mixture is 
next heated to a temperature of 122° F., and the paraffine 
solution is then applied to the surface of the burn by means 



DRESSING OF WOUNDS 329 

of an atomizer, or spread over the surface with a camel's-hair 
brush. At the first dressing the application of liquid petro- 
latum to the burned surface before applying the paraffine 
mixture may be used, as it seems to diminish the pain. 

After applying the first layer of the paraffine mixture, a 
thin layer of absorbent cotton is spread over the surface of the 
burn, then a second layer of the paraffine mixture is next 
applied, and the dressing is completed by the application of 
a canton-flannel bandage. Dressings should be renewed at 
intervals of one or two days, and at each dressing blebs should 
be opened and dead tissue removed. Superficial burns heal 
more rapidly under the paraffine treatment than by any 
other method, but in deep burns the results are not so 
brilliant. The resulting scars under the paraffine dressing 
are softer and are less likely to be followed by contractures 
in burns of moderate depth, but in deep burns severe con- 
tractures may result. 

Horse Serum. — Robinson has recommended horse serum 
for the treatment of burns, with the object of hastening the 
epidermization by furnishing nourishment to the cells at the 
wound margin, and thus stimulating them to proliferation. 
Normal serum, with a small percentage of tricresol, should be 
sprayed upon the surface of the wound several times a day 
for ten days, the surface of the wound in the meantime being 
covered with rubber tissue. 

Dichloramine- T Dressing. — This preparation has been 
recently recommended as an efficient dressing in the treat- 
ment of burns. Dr. W. E. Lee has reported excellent results 
in the treatment of burns and scalds following the use of 
dichloramine-T. The dichloramine dressing is as follows: 
The devitalized tissue should be softened by soaking in saline 
solution and removed as far as possible. The surface of the 
wound should be dried by fanning or a hot air blower. When 
this has been accomplished the wound is painted over with 
a -J--Q of 1 per cent dichloramine, and a layer of wide-meshed 
paraffine gauze applied, extending in all directions, a little be- 
yond the edges of the wound. A number of layers of sterilized 
gauze are next applied, and held in contact with the wound by 
a gauze bandage or strips of adhesive plaster. The dressings 



330 MINOR SURGERY 

should be changed daily or with intervals of a day. The 
strength of the dichloramine should be gradually increased 
from 4^ of 1 per cent up to 1 or 2 per cent if its application 
is painless. Another method consists in applying the dichlo- 
ramine and paraffine gauze and allowing the wound to remain 
exposed to the air. 

If the wound is relatively aseptic the healing progresses 
rapidly, and subsequent contractures are avoided or dimin- 
ished. 

Burns and Scalds of the Tongue, Pharynx, Glottis and Epiglot- 
tis. — These may result from taking hot liquids into the 
mouth, or from the inhalation of steam, hot vapor or steam ; 
the introduction of caustic alkali in the mouth produces 
similar lesions. There is great swelling of the tongue and 
mucous membranes, the formation of vesicles, shock, pain, 
dysphagia, dyspnea and edema of the glottis. 

Treatment. — Shock should receive appropriate treatment, 
vesicles should be punctured, ice should be held in the mouth, 
and if the tongue is greatly swollen multiple longitudinal 
incisions of the dorsum of the tongue should be made. If 
edema of the glottis is present, as evidenced by dyspnea, 
scarification should be employed and if, in spite of this pro- 
cedure, dyspnea is increasing, tracheotomy should be done. 
Intubation is not likely to be of service as the edematous 
tissues would occlude the opening in the tube. 

Burns of Esophagus. — These are seldom caused by hot 
liquids, which rarely pass beyond the pharynx, but are more 
apt to result from the swallowing of caustic alkali or acids. 
As the result of this accident there will be shock, pain, severe 
thirst, vomiting of blood, and there often follows severe 
gastritis. After the acute symptoms subside, sloughs are 
cast off, ulcers form, and cicatrization takes place, with the 
development of signs of stricture of this organ. 

Treatment. — If a caustic alkali has been swallowed, use 
mild acidulated drinks, wash out the stomach with acidulated 
water to counteract the alkali. If acids have been swallowed 
alkaline drinks, such as lime water, should be employed — also 
for lavage. Treat shock, if present. Give morphine for the 
relief of pain. Feed the patient by the rectum until he shows 



DRESSING OF WOUNDS 331 

signs of failing strength, then give concentrated nourishment 
by the mouth — beef tea and soft-boiled eggs. Start the use 
of bougies early, in second or third week, to limit contracture 
of the organ and prevention of stricture. 

Burns of the Hands and Fingers. — The contracture and 
deformity following burns of the hands and fingers often 
result in so much loss of function as to render the members 
useless. With this possibility in view, proper dressing should 
be selected, and the greatest care should be observed to keep 
the parts in proper position by the use of splints during and 
after the healing of the burn. Care should be taken to pre- 
vent adhesion of raw surfaces, especially in the fingers, result- 
ing in webbing of these members. By dressing each finger 
separately to prevent contact of the raw surfaces, and the 
early resort to skin grafts, much can be done to prevent this 
crippling deformity. Burns of the feet and toes should 
receive the same attention. 

Contractures from Burns. — The amount of scar tissue pro- 
duced in the healing of burns and the consequent contractures 
are in direct relation to the severity and duration of the infec- 
tion. In burns and scalds involving the face, neck, hands, 
feet and the region of the joints, the possibility of serious 
deformities from contraction of the tissues should not be lost 
sight of, and position, extension, splints and bandages should 
be employed to prevent as far as possible this complication. 
The use of braces in the case of burns in the region of joints 
and the neck is, even after healing has occurred, most useful 
in preventing deformity. 

Skin Grafting. — This procedure should be resorted to early 
in the ulcerated surfaces resulting from burns, as soon as the 
surface is in condition to receive grafts. By so doing both 
the time of repair and the tendency of contracture of the 
scar tissues is diminished. 

Ulcers resulting from separation of the dead tissues should 
be touched with a solution of nitrate of silver, 5 grains to 1 
ounce of water, and dressed with lint spread with an ointment 
of boric acid, aristol or ichthyol. Repair in the chronic 
ulcers following burns and scalds is often very slow. In such 
cases the use of an ointment of scarlet red will be found most 



332 MINOR SURGERY 

effective in hastening the healing: Scarlet red, grs. viij; ac. 
boric, 3ss; nngt. petrolatum, 5j. 

Effects of Cold. — The results of exposure of the body to 
cold depend more on the length of the exposure than upon 
the intensity of the cold. Moist cold produces more serious 
results than dry cold. Hunger, fatigue and alcoholism render 
the subject more susceptible to the effect of cold. Prolonged 
exposure to cold causes pain in the limbs, lassitude, somno- 
lence, coma and death if the patient is not actively treated. 
Death may result from cerebral anemia, from sudden and 
progressive chilling, or cerebral congestion from slow and 
continuous chilling or embolism in cases when the patient is 
exposed to sudden warmth. 

Frost-bite. — This is most frequently seen in the fingers, toes 
nose, ears, cheeks and chin, but may involve the penis, feet, 
legs, hands and arms. The local effect of cold is analogous to 
that of heat, erythema, vesication and sloughing. Cold 
causes a primary contraction of the vessels and pallor and 
numbness of the part which is followed by dilatation of the 
vessels with redness, swelling and burning pain in the affected 
part. In a moderate frost-bite the swelling and redness dis- 
appears in a few days. In more severe frost-bites the part 
becomes purple and covered with vesicles, the cuticle is 
destroyed and infection follows and painful ulcers develop; 
local areas of gangrene form or large portion of the limbs 
may become gangrenous. 

Treatment. — In the milder varieties of frost-bite, in which 
the skin is livid but not gangrenous, friction with snow or 
rubbing with towels should be employed until sensation is 
restored and the parts should then be wrapped in cotton. 
In severe cases, when localized or extensive gangrene occurs, 
the parts should be covered with warm antiseptics to favor 
the suppuration of the sloughs. When this has occurred the 
resulting ulcers require appropriate treatment. In gangrene 
of the limbs amputation is required which should not be done 
until the line of demarcation is well established. 

Pernio or Chilblain. — This is a vasomotor disturbance which 
is characterized by burning, pain and redness of the skin 
which follows frost-bite of moderate degree. This may dis- 



DRESSING OF WOUNDS 333 

appear and afterward recur on exposure to slight cold. The 
parts most frequently involved are the feet, fingers, toes, 
heels, cheeks, nose and ears. The patient should wear woolen 
stockings in cold weather if the feet or toes are affected, and 
not bring the parts near a fire. The local treatment by paint- 
ing the parts with tincture of iodine or tincture of belladonna 
often relieves the condition ; friction with alcohol or campho- 
rated soap liniment may do good or an ointment of emp. 
plumbi and petrolatum, equal parts, or one composed of 
pulv. camphorae (5j), ichthyol, (5iss) lanolin (5ss) and 
petrolatum (Biv) often relieves the pain and itching; the 
parts should be wrapped in cotton after applying this 
dressing. 

Injuries from Electricity. — Since the extensive introduc- 
tion of electricity in the arts, injuries from contact with 
heavily charged wires are of frequent occurrence. If the 
current be a strong one, death may be instantaneous, or the 
patient may be knocked down, become unconscious and pre- 
sent severe burns at the point of contact, then regain con- 
sciousness and subsequently suffer from numbness in the 
extremities, traumatic neuroses and in rare cases true paraly- 
sis. If the skin be dry at the time the current is received 
there will be more burning, less penetration and less shock and 
less danger of death. The burns are not painful, but are apt 
to be followed by extensive sloughing. Alternating currents 
are more dangerous than continuous currents; a continuous 
current of 1000 volts is not apt to be followed by serious 
consequences, whereas an alternating current of the same 
strength is likely to produce death. 

Death from exposure to strong alternating currents is con- 
sidered by Hedley to be caused by destruction of the tissues 
or by arrest of respiration producing asphyxia. Exposure to 
a strong electric current may produce burns or ecchymoses, 
and occasionally wounds; the latter bleed freely and are apt 
to slough. A burn from electricity presents a dry blackened 
surface and is surrounded by an area of pale skin. They are 
not as painful as ordinary burns, but healing in electric burns 
is usually slow. Inflammation and suppuration of the tissues 
usually develop in a few days, and are often followed by the 



334 MINOR SURGERY 

development of an extensive area of moist gangrene, a small 
burn being followed by extensive and deep destruction of the 
surrounding tissues. 

If the body of the person receiving the electric current is 
still in contact with the wire it should be removed as quickly 
as possible. It is not wise to lift the body with bare hands. 
Rubber gloves, if available, should be worn ; if not, the hands 
should be covered with dry woolen cloths before lifting the 
body. 

Treatment. — The treatment of a person who has been 
exposed to a strong electric current, even if apparently lifeless, 
consists in practising artificial respiration. If the heart's 
action can be detected there is a chance of resuscitation; if 
both cardiac action and respiration are present the prognosis 
is favorable, Laborde's or Silvester's method being employed; 
also friction to the surface of the body and enemata of hot 
saline solution or infusion of saline solution with adrenalin 
into a large artery, as recommended by Crile; in some cases 
venesection has been employed with advantage. Hedley 
records a case of apparent death in a man who received an 
alternating current of 4500 volts short-circuited through his 
body for many minutes, who showed no signs of life for thirty 
minutes. In this case, after the employment of Laborde's 
method of artificial respiration for some time, normal respira- 
tory action was restored and the patient recovered. Artificial 
respiration should be practised in all cases, and should be 
continued until it is certain that the patient is dead. At the 
same time strychnine should be used hypodermically. 

The burns should be treated by the application of anti- 
septic dressings, but these often fail to arrest the sloughing. 
DaCosta recommends in the early stage of these burns the 
use of fomentations of hot saline solution, which facilitates 
separation of the sloughs, and in the subsequent dressing 
of the wounds peroxide of hydrogen followed by irrigation 
with saline solution. After sloughs have separated dry 
sterilized dressings should be employed. 

Lightning Stroke. — This results from the discharge of 
atmospheric electricity, and injuries from this cause are 
more frequent in the summer season. In this form of electric 



DRESSING OF WOUNDS 335 

injury a person may be struck directly or may be shocked by 
an induced current, the lightning having struck some object 
near at hand. The results of lightning stroke upon the body 
differ according as the electrical or the burning action pre- 
dominates. There may be present severe burns or extensive 
lacerations, involving the muscles, bloodvessels and bones; 
or sudden death may result from paralysis of the respiration 
and circulation. Upon regaining consciousness, the patient 
may complain of disturbance of vision, and may suffer from 
paralysis of the nerves of motion or sensation; paralysis of 
the lower limbs is said to be more common than that of the 
upper limbs. 

Treatment. — The treatment of the stage of shock following 
lightning stroke consists in the application of external heat, 
heat, the employment of artificial respiration and the admin- 
istration of stimulants. If burns exist upon the surface of 
the body they should be treated like burns arising from 
artificial currents. If paralysis persists for some time after 
recovery from the immediate effects of the shock the use of 
galvanism and the administration of strychnine may be 
followed by good results. 

Roentgen-ray Burns. — A peculiar lesion of the skin and 
subjacent tissues, following prolonged exposure to the roent- 
gen rays, resulting in inflammation, dermatitis or ulceration 
of the skin and loss of the nails and hair in the damaged area, 
is described as an roentgen-ray burn. This lesion differs from 
an ordinary burn in that it may not appear for several days 
or weeks after the exposure, and that the inflammatory or 
gangrenous process arises in the tissues and finally involves 
the skin. Chronic roentgen-ray burns give rise to indolent 
ulcers, which in time undergo malignant change. These 
lesions are very painful and slow in healing; and if an exten- 
sive surface be involved they may result in serious conse- 
quences: amputation of the fingers or a limb has been 
demanded by reason of a burn of this nature. The lesion is 
probably due to trophic changes. 

Treatment. — The dressings employed in ordinary burns have 
not proved satisfactory in these injuries. Where dermatitis 
with intense itching is present a paste composed of boric 



336 MINOR SURGERY 

acid, 5j; zinc oxide, 5j; starch, §j; bismuth subnitrate, 
5 j ; olive oil, § j ; lime water, 5 iij ; lanolin, 5 iij ; rose water, 
5xij is spread on lint or gauze and applied to the part. 
Dry sterilized dressings may be employed and skin grafting 
when the ulcerated surface is extensive may be of service. 
The latter procedure is found most efficacious after exclusion 
of the base of the ulcer. When a small area only is involved, 
and healing fails to occur, Powell recommends excision of the 
ulcerated tissues. Amputation may be necessary. 

Bed Sores (Decubitus). — The local failure of nutrition in a 
subject with tissues of low vitality from age, disease, or injury 
may result in the development of a bed sore. Development of 
a bed sore in the aged is favored by their arterial condition. 

Bed sore, in favorable subjects, results from continued pres- 
sure upon a part, aided by slight injury or irritation which 
may be caused by contact with urine, feces, sweat or foreign 
bodies. 

Vascular tone is diminished by pressure; stasis results, 
thrombosis occurs and gangrene results. They are also a 
frequent and troublesome complication in spinal injuries, in 
which cases they result from trophic disturbances. 

The parts most subject to bed sores are the sacral region, 
buttocks, scapulae, heels, trochanters and elbows. Their 
formation may be prevented in many cases by the use of air 
cushions or of a water mattress, and by keeping the parts 
exposed to pressure scrupulously clean and frequently bath- 
ing them with stimulating lotions, such as alcohol, olive oil 
and alcohol (equal parts) or soap liniment. The parts should 
also be protected from pressure by the use of small pads or 
pillows so arranged as to relieve the part of pressure. When 
a bed sore has actually formed — and in many cases its forma- 
tion is very rapid and the slough will be found to involve a 
large surface of the skin over the sacrum, and to extend down 
to the bone — we have present a very serious complication, 
and one which requires most careful treatment. 

The dressing of a bed sore before separation of the slough 
consists in relieving the part from pressure by the use of an 
air cushion placed under the buttocks, and the application 
of a moist antiseptic dressing until the slough has separated, 



INJURIES OF JOINTS 337 

When the slough has become detached the ulcer remaining 
should be well irrigated with a 1:2000 bichloride solution, 
and the granulations touched with a 5-grain solution of nitrate 
of silver; and aristol, or boric acid ointment spread upon lint, 
should be applied to the surface of the ulcer or dichloramine-T 
may be used. This dressing should be renewed every day 
or every other day, and means should be adopted to protect 
the parts from further pressure, and the constitutional con- 
dition of the patient should be improved by the administra- 
tion of a nutritious diet, tonics and stimulants. The applica- 
tion of the galvanic current has been employed to promote 
healing of the ulcer in obstinate cases. 

INJURIES OF JOINTS. 

Contusion of Joints. — This injury results from force 
directly applied to the surface of the joint, or from force 
transmitted through the adjacent bones, as is not infrequently 
observed in the knee-joint after fracture of the femur. The 
part becomes swollen and tender, and the joint assumes that 
position in which there is the least tension. The swelling 
is due to effusion and hemorrhage in the joint and the contu- 
sion of the soft parts. The swelling and tenderness usually 
subside in a short time under the application of cold-water 
dressing, or an ice-cap, and fixation of the joint for a short 
time with a splint. Pressure by a firm bandage, hot-air bak- 
ing and massage may be useful. 

Hemarthrosis. — This condition, in which blood has escaped 
into the joint, resulting from a subcutaneous wound or severe 
contusion or sprain, is most frequently observed in the knee- 
joint. The joint becomes swollen and painful and there is 
loss of function. Cold-water dressing and fixation of the 
joint should be applied and later pressure by a bandage. If, 
in spite of treatment, the swelling remains and is painful, 
arthrotomy, with the removal of the blood, should be prac- 
tised. The wound should be closed without drainage. 

Sprains of Joints. — A sprain is caused by a sudden wrench 
or twist of a joint, which stretches or lacerates the ligaments, 
contuses or crushes the synovial membranes, and may loosen 
22 



338 MINOR SURGERY 

or separate the cartilages. The joints most frequently 
involved are the knee, elbow and wrist, but the smaller joints 
may also be involved. The ball and socket joints are less 
frequently involved than the hinge joints. In the foot the 
subastragular joint often presents this injury. A careful 
examination should be made to eliminate the presence of 
fracture. As the swelling appears early and is often marked, 
it may be difficult to obtain this information unless a roent- 
gen-ray examination is made. Sprain-fracture, which was 
described by Callender as the tearing of a ligament or tendon 
from its point of insertion, with the detachment of a thin 
shell of bone, often complicates sprains of joints. 

When seen early, strapping of a sprained joint and the 
application of a firm bandage is the most satisfactory dressing, 
as it gives the parts support and limits the swelling If the 
sprain is seen late and the parts are much swollen and painful 
wet dressing and a firm bandage should be applied for a few 
days, and as soon as the swelling has diminished strapping 
should be employed. I have found that with this form of 
dressing the patient has restoration of function much sooner 
than with any other form of dressing. With a properly 
applied strapping of the ankle or knee-joints patients are 
able to walk without discomfort in a few days. The applica- 
tion of strapping to a sprain of the ankle-joint is seen in 
Fig. 243). 

The strapping should be renewed in five or six days, and 
may be dispensed with in two or three weeks. Absolute fix- 
ation of the sprained joint with a plaster-of-Paris dressing was 
formerly much used in the treatment of sprains, but as it 
tends to promote stiffness and interferes with the circulation 
it is now seldom employed. In severe sprains induration 
and tenderness often persists for some time. In such cases 
baking and massage should be employed. 

Wounds of Joints. — As joints are very susceptible to infec- 
tion, any wound which opens the joint is a most serious lesion. 
Penetrating joint wounds may result from incised, lacerated 
and gunshot wounds and fractures of adjacent bones. All 
wounds of joints are attended with danger, but those of the 
knee and vertebral joints are the most dangerous; the great 



INJURIES OF JOINTS 



339 



risk in these wounds is infection. If proper treatment is 
not promptly undertaken infection of the joint develops 
rapidly, followed by septicemia and death. When a joint 
is opened by a wound there is a flow of synovial fluid; this 
also occurs in wounds of bursas in the neighborhood of the 
joint. In punctured wounds, if small, the escape of synovial 
fluid is not apt to occur. When a joint is opened by the 



Fig. 243. 




Strapping applied to ankle-joint. 

surgeon with full antiseptic precautions it usually heals under 
rest and aseptic dressings without untoward symptoms. 
In accidental penetrating wounds of joints infection is 
likely to occur. 

Treatment. — Small punctured wounds of joints by instru- 
ments which are not likely to introduce infection, may be 
treated by painting the wound and surrounding skin with 
tr. iodine and applying a sterile gauze dressing. The joint 



340 MINOR SURGERY 

should be put at rest upon a splint, the patient being carefully 
watched for symptoms which point to infection of the joints. 
If infection occurs radical treatment should be promptly 
undertaken. In wounds in which it is likely that infection 
has been introduced — incised, lacerated, gunshot and punct- 
ured wounds — the wound should be packed with sterile gauze, 
and the limb surrounding prepared as for an aseptic operation. 
The wound should be enlarged if necessary, foreign bodies 
extracted and blood clots removed, and devitalized tissues 
trimmed away with the knife or scissors. The joint should 
be next irrigated with warm saline solution, and the capsule 
sutured. Primary flushing of the wounds with ether was 
practised during the late war, with apparently good results. 
After providing for drainage of the overlying soft parts the 
wound is sutured and covered by a sterile gauze dressing. 
The joint is immobilized by a splint or plaster-of-Paris dress- 
ing, elevated and surrounded by ice-bags, and in the larger 
joints weight extension should be applied. If there is absence 
of pain and fever the drainage should be removed at the end 
of the second day, and fixation of the joint kept up for two 
weeks. At this time, if the wound is healed, passive motion 
to restore the function of the joint should be practised. 
Unfortunately, the joint wound may not take the course 
described above. A few days after the first dressing signs of 
infection may appear, as evidenced by swelling, pain, fever 
and marked leukocytosis, indicating the development of 
septic arthritis. The dressings should be removed and 
drainage instituted, either by opening the original wound 
or by making counter-incisions. Fixation of the joint should 
be continued, and it should be irrigated two or three times a 
day through the openings with saline solution, or instil- 
lation of Dakin's solution may be employed. Free inci- 
sion of the joint and chemical sterilization has also been 
employed in these cases. Wilms, in cases of suppurative 
arthritis, recommends opening the joint by one or more 
incisions, and have the patient make active movement of 
the joint every few hours, claiming that movements of the 
joint force the pus from all crevices of the articulations, thus 



INJURIES OF JOINTS 341 

securing the best drainage. In applying this treatment to 
septic arthritis of the knee-joint the part is surrounded by 
a copious gauze dressing, and is kept upon a splint with exten- 
sion. At intervals of a few hours the splint and extension 
are removed, and the patient makes active movement of the 
joint for a few minutes; this procedure is repeated every 
few hours. This method is still under trial. Good results 
have been recorded in a number of cases. My experience in 
a limited number of cases has been favorable. 

In spite of the above treatment, if the septicemic symptoms 
continue or increase, the question of excision or amputation 
has to be considered, and it is well not to postpone these 
radical operations too long, for if done late in the disease, even 
they may fail to save the patient's life. 

Sprain-fracture. — Under this name Mr. Callender has 
described an injury which consists in the separation of a liga- 
ment or tendon from its point of insertion into a bone, with 
the detachment of a thin shell of the bone; this injury is apt 
to occur about the ankle-joint, knee-joint, elbow-joint and 
wrist-joint, and the treatment is the same as that of an 
ordinary fracture in the same locality. This injury is prob- 
ably much more common than is generally supposed in con- 
nection with sprains of the joints and is, I think, in many 
cases the cause of tardy restoration of the function of sprained 
joints, this injury being overlooked, simply being treated as 
a sprain, and the patient being encouraged to use the part 
before union of the bone has been accomplished. The fre- 
quency of sprain-fracture has in recent years been demon- 
strated by roentgen-ray examination. 

Strains of Muscles and Fascia. — These vary in severity 
from simple stretching of the fibers to absolute rupture, and 
should be treated by putting the parts at rest and by the 
application of pressure by means of adhesive straps or of a 
bandage; in strains of the muscles and fascia of the back the 
use of broad strips of adhesive plaster, applied as in cases of 
fracture of the ribs, will be found most satisfactory. In the 
treatment of the later stages of these injuries the employment 
of baking and massage will often be followed by good results. 



342 MINOR SURGERY 



VACCINE THERAPY. 

The bodily resistance to an infection may be increased by 
the injection of a vaccine. Vaccines are prepared by taking 
a culture of the infecting organism from the local focus of 
inflammation, the wound, or the blood, and a pure culture is 
made. If several organisms are present cultures of the most 
pathogenic type are grown; this occurs in thirty-six hours. 
The organisms which are made into an emulsion with salt 
solution, known as bacterins, are destroyed by heat and are 
injected with aseptic precautions into the subcutaneous 
tissues or muscles of the patient. 

The work of Wright and Douglas led to the discovery of 
substances in the blood known as opsonins, whose function is 
to act upon bacteria in such a way as to make them more 
easily destroyed by phagocytes. The injection of an emul- 
sion of bacterins increases the opsonic power of the patient's 
blood, presumably by stimulating the opsonic power of the 
patient's blood by stimulating the opsonic forming elements 
of the body. 

This treatment is based on the principle of exciting the 
formation of antibodies in the system and the destruction of 
bacteria by them and the leukocytes. Antibodies which 
destroy most bacteria exist constantly in the blood, and their 
formation is actively stimulated by antigens such as bacterial 
toxins. A vaccine made from a certain variety of organisms 
is valuable only in infections caused by that variety of 
organism. Stock cultures are sometimes employed, but it is 
better to use, whenever possible, bacteria obtained from the 
infected person, and make the vaccine from them. This is 
known as an autogenous vaccine. In cases of emergency 
stock vaccines may be used until an autogenous vaccine can 
be prepared. 

Mixed vaccines are also used, with excellent results in cases 
of mixed infection, prepared by combining the vaccines of 
staphylococci, streptococci and colon bacilli, etc. 

The dosage of bacterins varies with the organism, the nature 
of the disease and the resistance of the patient. The injec- 
tions of vaccines appear to be free from danger. Staphylo- 



DISEASES COMPLICATING WOUNDS 343 

coccic vaccines give better results than streptococcic. It is 
better to begin treatment with a small dose rather than a 
large one. A moderate dose of staphylococcic vaccine is from 
50,000,000 to 200,000,000; streptococcic vaccine is given in 
doses of 15,000,000 to 50,000,000. A moderate reaction often 
follows the injection of bacterins, such as slight rise in 
temperature, headache, backache and languor. 

There is no doubt of the value of this form of treatment in 
certain cases; in acne vulgaris, furunculosis and carbuncle, 
their use seems to be especially effective. They are also 
employed with good results in septicemia following wounds 
and abscesses, joint infections, osteomyelitis, endocarditis, 
pericarditis and meningitis. 



DISEASES COMPLICATING WOUNDS. 

Septicemia or Sepsis. — This is a febrile affection caused by 
the introduction into the blood of pyogenic organisms, their 
toxins, or those of saprophytic bacteria, staphylococci, 
streptococci or pneumococci may be the causative agent. 
The absorption of septic matter by the lymphatics is an 
important agent in its production; a wound is the usual portal 
of entry. We recognize three forms of septicemia: (1) Sep- 
tic infection which may be mild in type, and progressive 
septicemia in which there may be a true bacteriemia; (2) 
pyemia; and (3) sapremia. 

Septic infection is manifested by elevation of temperature, 
rise in pulse-rate, headache and nausea. These symptoms 
may be present for a few days and recovery takes place. The 
severe form of progressive septicemia may follow the milder 
form and is ushered in by a chill followed by high fever, 
rapid, weak, compressible pulse, delirium alternating with 
stupor and coma usually develops before death in this form 
of infection. A true bacteriemia may be demonstrated by 
blood culture. The prognosis is not good if bacteriemia exists. 

Treatment. — The wound should be sterilized by the use of 
Carrel-Dakin treatment or dichloramine-T and the patient 
should be given tonics and stimulants with a supporting diet, 



344 MINOR SURGERY 

and if improvement does not promptly occur vaccines or 
polyvalent serum should be employed. Hooker has in such 
cases recommended the transfusion of immunized blood, the 
donor being immunized by progressively increasing doses of 
a freshly made vaccine from the causative organism. 

Pyemia. — This affection is characterized by fever of an 
intermittent type, recurring chills and the development of 
metastatic abscesses as the result of septic thrombophlebi- 
tis. The entrance into the blood of clots filled with toxins 
or clots infected with streptococci or staphylococci from an 
infected wound is the usual cause of this infection. Suppu- 
ration in contact with a vein may cause thrombophlebitis 
and clot formation if no wound exists. Portions of the 
infected clots are carried by the blood stream to different 
parts of the body and lodge in the smaller vessels giving rise 
to embolic, secondary or metastatic abscesses. This affec- 
tion may arise from the infection of superficial or deep 
wounds, the medulla of bone or erysipelas. 

Symptoms. — A severe chill, followed by high fever and 
profuse sweats usually ushers in the disease. The chills and 
sweats recur at intervals, during the sweating the temperature 
may drop to the normal, jaundice may occur and there may 
be suppuration of the parotid gland or purulent arthritis. 
Acute pyemia may prove fatal in a few days; the chronic 
condition may last for months. 

Treatment. — This is similar to that of septicemia — abscesses 
if accessible should be evacuated and vaccines should be 
employed as soon as the disease declares itself. 

Sapremia (Putrid Intoxication). — This arises from the 
absorption of poisonous ptomaines from putrefying tissues. 

Symptoms. — There is often a chill; the temperature rises to 
103° F. or higher; headache, dry coated tongue, nausea, vomit- 
ing, rapid and weak pulse and jaundice may be present; 
petechial spots may appear upon the skin; leukocytosis may 
be marked. Visceral complications, nephritis, cholecystitis, 
pleuritis, pericarditis or endocarditis may occur, which require 
appropriate treatment. 

Treatment. — The wound should be drained, antiseptic dress- 
ings applied and attempts to render the wound aseptic should 



DISEASES COMPLICATING WOUNDS 345 

be made. Carrel-Dakin treatment should be employed. The 
patient should be given stimulants. Alcohol, strychnine and 
digitalis, a nourishing diet, purgatives, diuretics and diapho- 
retics should be administered to aid in removing the toxins. 
Hypodermoclysis or the intravenous use of saline solution 
may be helpful. 

Erysipelas. — This is an inflammation of the skin and sub- 
cutaneous cellular tissues caused by infection of the small 
lymphatics by streptococci. The infection occurs through 
an ulcer wound or scratch, which in some cases is difficult to 
locate. Many different varieties of erysipelas have been 
described, but for practical purposes that involving the skin 
and that in which the skin and subcutaneous cellular tissue 
are both involved need only be considered; the latter may 
result in the formation of abscesses (phlegmonous erysipelas) . 

The skin in the region of a wound, in the course of lym- 
phatic vessels draining the region of the wound, becomes red 
and slightly elevated. The disease may show itself on parts 
of the body where no wound can be located. The face and 
bridge of the nose is a frequent seat of origin. Here the lesion 
may be in the scalp or the mucous membrane within the nose. 
The redness, whose margin is sharply defined, spreads rapidly, 
and may involve a large portion of the skin of the body and 
blebs may form on the surface. The ears are not often 
involved on account of the close adhesion of the skin to the 
cartilage. 

Symptoms. — There is burning pain and swelling in the 
involved area. The lymphatic glands are enlarged, the pulse 
is increased and the temperature elevated. If the disease 
ceases to spread the redness and swelling gradually abate and 
desquamation occurs. On the other hand the area involved 
may become more swollen and edematous and dusky in color 
and areas of softening may be found, pointing to the develop- 
ment of abscess. In young and strong subjects the symp- 
toms of cutaneous erysipelas are often slight, but in old and 
debilitated subjects serious symptoms develop, rapid pulse, 
dry brown tongue, high temperature, delirium and death. 
Pneumonia, meningitis, endocarditis, arthritis and albumi- 
nuria may develop as serious complications. 



346 MINOR SURGERY 

Treatment.— If a wound is present it should be rendered 
aseptic if possible. The patient should be isolated. Wet 
dressing, boric acid or magnesium sulphate may be applied 
over the inflamed area or the surface should be frequently 
painted with ichthyol, 25 parts, olive oil, 75 parts, or an 
ointment containing ichthyol and lanolin or vaseline, 
equal parts, should be applied. The dresser should wear 
rubber gloves to prevent transferring the affection to other 
subjects. 

To arrest the spreading of disease, painting the skin outside 
of area with a broad band of tincture of iodine has been 
recommended. Constitutional treatment appropriate for the 
inflammatory condition should be given. Tincture of chlo- 
ride of iron and quinine, the former given in the form of 
Basham's mixture, have long been used in this affection with 
good results. In phlegmonous erysipelas, with purulent infil- 
tration of the subcutaneous tissues, free incisions should be 
made for drainage and wet antiseptic dressings applied. The 
grave constitutional symptoms call for the use of strychnine, 
quinine, digitalis and alcohol. Antistreptococcic serum may 
be employed. 

Cellulitis. — This results from a streptococcic or staphylo- 
coccic infection of the subcutaneous cellular tissues, with 
involvement of the lymphatic channels, which appear as red 
lines upon the skin, with enlargement of associated lymphatic 
glands. The skin is not often involved; there may be red- 
ness, but less marked than in erysipelas. In mild cases the 
lymphatics dispose of the infection, and there are few symp- 
toms. Pain of a throbbing character is often present. If 
the infection is more severe there may be symptoms of infec- 
tion, rapid pulse and rise in temperature and suppuration in 
the lymphatic glands. 

Treatment. — The constitutional treatment should be that 
employed in septic infection: Rest of the affected part and 
hot antiseptic dressings applied to the wound; the area about 
the wound should be painted with tincture of iodine, or 
covered with ichthyol ointment. If suppuration involves the 
lymphatic glands, incision and removal of the broken down 
glands should be practised. 



DISEASES COMPLICATING WOUNDS 347 

Air Embolus. — Air may enter a vein during operations or 
be accidentally injected in giving hypodermic injections or in 
saline hypodermoclysis or intravenous infusion. It was 
formerly considered a very fatal accident, but recent investi- 
gation has shown that a certain amount of air can enter the 
veins without causing grave symptoms. The danger depends 
upon the amount of air and the rapidity of its entrance. The 
cause of death in air embolism is supposed to be due to the 
mixing of air with the blood in the right side of the heart, 
interfering with the normal action of the valves and the pro- 
pulsion of blood into the lungs. 

Symptoms. — These develop with great rapidity; extreme 
failure of circulation, with a churning sound on cardiac systole, 
marked pallor or cyanosis, gasping for air and convulsions. 

Treatment. — Suspend the anesthetic, compress with the 
finger, or clamp the divided vein, lower the head and make 
artificial respiration. Give strychnine hypodermically, and 
normal salt solution and adrenalin intravenously. 

Fat Embolism. — Fat may be forced into open veins in 
wounds by muscular action. Wilms believes it enters the 
veins by way of the lymphatics and thoracic duct. Fat in the 
blood is quite a common condition and seldom produces 
serious symptoms. Fat embolism may occur in fractures of 
long bones, in extensive bruises and crushes, amputations, 
excisions and rupture of the liver. 

Lipemia probably results when laceration of the vessels 
occur in fatty tissues, and the presence of fat in the urine — 
lipuria, is not uncommon after fractures, especially of the 
long bones. The presence of fat in the urine after fracture 
should warn against early movements of the fragments. 

If numerous emboli block the capillaries of a vital organ, or 
large emboli lodge, marked symptoms arise. 

Symptoms. — Restlessness, dyspnea, rapid weak pulse, rapid 
respiration, contracted pupils, pallor followed by cyanosis, 
edema of the lungs and exhaustion. 

Treatment. — Complete immobilization and infrequent dress- 
ing of the injured or diseased part. External heat, strych- 
nine, alcohol and nitroglycerin. If respiration is much 
embarrassed artificial respiration may be useful. Drainage 



348 MINOR SURGERY 

of the region of fracture or injury should be made, as fat 
enters the vessels gradually under pressure. 

Thrombosis. — This consists in coagulation of blood in a 
vessel partially or completely occluding it, the clot or coagu- 
lum remaining at the point of origin. The clot or thrombosis 
consists of red and white corpuscles, fibrin and platelets; it 
forms gradually, being deposited layer by layer, and may 
occur in arteries, veins or capillaries. Thrombosis occurs 
from chemical alterations in the blood, changes in the interior 
of the vessel by bacterial infection, changes in the inner coat 
of the vessel and slowing of the circulation. In arteries, 
changes in the coats and embolism are the chief causes of 
thrombosis. The essential cause of all intravascular thrombi 
is damage to the endothelial coat usually effected by bacteria 
and therefore is infectious. An excess of fibrin forming 
elements in the blood, and slowing of the circulation also 
favor thrombosis. By testing the coagulability of the blood 
the danger of thrombosis and embolism may be suspected. 
Wounds, fractures, ligation or wounds of vessels, pressure of 
splints, foreign bodies in a vessel, suture of vessels and 
atheroma of arteries are all active causes of thrombosis. 
Thrombosis may follow abdominal operations and general 
infections as in cases of pneumonia, typhoid fever and 
appendicitis. Mesenteric thrombosis, either arterial or ven- 
ous, causing gangrene of the intestine, is also occasionally 
observed. 

Treatment. — If an aseptic thrombosis develops in a large 
vessel of a limb the part should be handled very carefully to 
avoid detachment of fragments (emboli) which may be swept 
into the circulation. Lift the limb, cover it with cotton and 
apply a bandage from the lower extremity; keep in slightly 
elevated position and apply heat to favor development of the 
collateral circulation as gangrene is in imminent danger in 
thrombosis. The part should be kept at rest for five or six 
weeks. An infected thrombosis in an accessible vessel should 
be removed after ligating the vessel on each side of the clot, 
the wound sterilized and dressed. In gangrene of the intes- 
tine from mesenteric thrombosis, if not too extensive, resec- 
tion of the gangrenous gut is often followed by recovery. 



DISEASES COMPLICATING WOUNDS 349 

Embolism. — This consists in the occlusion of a vessel by a 
foreign body usually a blood clot which has been brought 
from a distant part of the vessel. This body is called an 
embolus and may consist of a fragment of a thrombus athe- 
romatous material from a distant artery, a shred of fibrin 
or portion of a tumor. An embolus is arrested when it 
reaches a vessel whose diameter is less than its own, or at the 
bifurcation of a vessel. An aseptic embolus may lodge and 
become organized, while an infected one is apt to soften and 
give rise to a number of smaller emboli, which escape into the 
blood stream and may cause metastatic abscesses. Collateral 
circulation may be established after the lodgment of an 
aseptic embolus. 

Symptoms. — These depend upon its situation, the organ 
involved and its freedom from infection. Embolism of the 
cerebral arteries or of the pulmonary artery are often fatal. 
If the main artery of a limb is involved there is pain at the 
seat of the embolus, the limb becomes cold and swollen and 
discolored, and the pulse is absent below the seat of the 
obstruction of the vessel. 

Treatment. — The limb should be elevated, kept at rest and 
heat applied to favor the development of the collateral circu- 
lation. If gangrene occurs amputation is demanded as soon 
as a line of demarcation is established. Emboli, either 
septic or aseptic, have been successfully treated by exposure 
and removal. 

Gangrene. — This term is used to describe the process of 
death of the soft parts in mass, the dead portions being large 
enough to be visible. Ulceration is caused by molecular 
death of the tissues; the dead parts are cast ofT in the form of 
pus. The term necrosis is usually confined to the death of 
bone, although it is often used to describe the death of soft 
parts, forming necrotic masses at some depth from the surface. 

The causes of gangrene are direct, where the death of the 
tissues is caused by crushing or pulpefaction of the parts, or 
destruction by caustics, heat, cold or electricity or virulent 
bacterial infection; or indirect, where the condition arises 
from interference with the blood supply. 

Gangrene is usually described as dry, when the condition 



350 



MINOR SURGERY 



arises where the arterial supply is cut off gradually by disease 
of " the artery, arteriosclerosis, or suddenly by an embolus; 
moist, which is usually due to venous obstruction, thrombosis, 
pressure of tumor or splints, or a tight bandage, and occa- 
sionally results from the sudden occlusion of an artery by 
embolism, wounds or ligature; microbic, in which bacteria or 
their toxins may cause gangrene by developing endarteritis, 
phlebitis and thrombosis. 

Dry Gangrene.— This usually develops in subjects well 
advanced in years, and is also known as senile or anemic 
gangrene, and is due to feeble action of the heart and a slowly 

Fig. 244. 




Dry gangrene from embolism. (Ashhurst.) 



progressing arterial occlusion from endarteritis and atheroma. 
The part involved becomes black, dry and mummified. The 
vessels in this condition do not carry a normal amount of 
blood and at any time may be occluded by thrombosis. Dry 
gangrene sometimes follows the sudden occlusion of an 
artery by an embolus (Fig. 244). A man with the above 
vascular condition is generally in feeble health, suffers from 
cold and numbness in the feet, and frequently complains of 
burning pain in the feet, especially at night. The arteries 
are felt as rigid tubes, like pipe stems. Gangrene usually 
appears upon one or more of the toes, and may follow a 
trifling injury, such as a bruise, cutting a corn too closely, or 



DISEASES COMPLICATING WOUNDS 351 

the rubbing of a shoe, or there may be no history of injury. 
A small purple anesthetic spot appears and is followed by a 
vesicle, which ruptures and discharges a small amount of 
bloody serum, exposing a dry floor. The tissues around this 
area show retarded and stagnated circulation, being purple 
in color, and those beyond the area are hyperemic. The part 
becomes black, dry and wrinkled and the process may be 
limited to one or more toes, or may gradually extend so that 
in time it involves the greater part of the foot, or even the leg. 
In senile gangrene the distal portion is dry, while that near 
the body is somewhat moist. As it spreads the area of hyper- 
emia at the margin advances and the area of stasis follows. 
A line of demarcation may or may not form; if it does a 
spontaneous amputation may take place. Coincident with 
the development of the gangrenous process, the patient com- 
plains of severe pain, and if the area is extensive, develops 
fever from septic absorption and death may occur from renal, 
pulmonary or cardiac complications, or from exhaustion 
caused by sleeplessness, pain, septic absorption or embolism. 

Treatment. — If the gangrene is limited to one or more toes, 
and shows no tendency to spread to the foot, no operative 
treatment need be considered. To prevent injury or infec- 
tion the part should be wrapped in dry sterile cotton. If the 
patient has no fever, nor exhausting diarrhea, and sleeps and 
takes nourishment well, formal amputation may never be 
required, as Nature will be able to remove the dead tissue 
at the phalangeal joints with less constitutional disturbance 
than would result from operation. If a line of demarkation 
forms and the parts are not separated spontaneously the 
surgeon can remove them with forceps and scissors and apply 
a dry antiseptic dressing. If, on the other hand, gangrene 
spreads to the foot and continues to extend, and the patient 
presents symptoms of septic infection, fever, diarrhea and 
sleeplessness, amputation should be done at the knee-joint, 
or just above the condyles of the femur. Some surgeons 
recommend amputation of the leg, but in my experience the 
disease is more apt to recur in the stump if the operation is 
done below the knee. 

Lejars, ' to determine at what level the limb should be 



352 



MINOR SURGERY 



removed, places an Esmarch bandage on the limb to exsangui- 
nate it, then applies the rubber band and removes the elastic 
bandage. The band should be removed in five minutes. It 
will be observed that the hyperemic blush which follows, will 
extend only so far as healthy circulation is present, and 
amputation may safely be done at this point. I have made 
use of this ingenious procedure, but its employment seems to 
be accompanied by a definite risk of injuring the artery and 
the formation of a thrombus at the seat of application of the 
rubber band. For this reason, in amputation of the thigh 
for senile gangrene, I never use the rubber band to secure 
hemostasis, but prefer to secure the arteries in the wound 
before they are cut. 

In many cases of senile gangrene the patient's condition is 
so poor that any operation would only hasten the fatal term- 
ination. Under such circumstances, of course, only palliative 
treatment is admissible. In dry gangrene following imme- 
diately the occlusion of an artery by an embolus, the surgeon 
should wait for the formation of line of demarcation and 
separation before resorting to amputation. 

Moist or Acute Gangrene. 
FlG - 245 - — In this form of gangrene 

the tissues may be actually 
destroyed by the trauma- 
tism, by strangulation of the 
tissues as seen in strangu- 
lated hernia, tumors with 
twisted pellicles or volvulus, 
or by the action of heat and 
cold or chemical irritants. 
Gangrene following the con- 
tinued application of carbolic 
acid to wounds is frequently 
seen. It is used in more or less diluted solutions as a house- 
hold remedy. It generally involves the fingers and toes 
(Fig. 245). * 

Moist gangrene may follow lacerated or contused wounds, 
compound fractures, burns and frost-bite, wounds of veins 
and arteries, or the ligation of arteries, or thrombosis or 




Gangrene following carbolic-acid dressing 
(Ashhurst.) 



DISEASES COMPLICATING WOUNDS 353 

embolism. It usually results from venous obstruction 
(thrombosis), pressure of tumors or constricting bands, the 
parts being surcharged with venous blood. When moist 
gangrene develops the part swells, the skin is first pale, cold 
and sensation is lost, and becomes livid, mottled and purple 
or greenish in color; blebs form beneath the epithelium which 
contain a reddish-brown fluid. The epithelium is loosened 
and may be slipped from the derma with little pressure. At 
the point where the resistive powers of the patient are able 
to overcome the destructive lesions producing the gangrene, 
a red line encircling the gangrenous structures forms, known 
as the line of demarcation. In this region the usual phenom- 
ena of inflammation occur, and as the process continues a 
line of granulations is formed, known as the line of separation. 
During this process the patient develops fever, due to 
sapremia from absorption from the gangrenous area. 

Treatment. — In moist gangrene the treatment should be 
directed to the prevention of infection and hastening the 
separation of the sloughing tissues. Warm antiseptic dres- 
sings should be applied, or the Carrel-Dakin treatment may 
be employed. In moist gangrene exposure of the part to 
sun or electric light is said to be valuable in preventing 
infection. The patient should be given morphine for relief 
of pain, tonics, nourishing food and stimulants. After the 
dead tissue has been separated the resulting granulating 
surface should be protected by antiseptic dressings. If the 
gangrene involves a limb, amputation should be done as soon 
as the line of demarcation and separation is established, at a 
point just above this line. 

Microbic Gangrene. — This is also described as gas gangrene 
or traumatic spreading gangrene. It frequently occurs in 
lacerated or gunshot wounds and compound fracture, and is 
due to a mixed infection with virulent streptococci and 
organisms of putrefaction, or to infection by the bacillus of 
malignant edema or Bacillus aerogenes capsulatus. Within 
twenty-four hours after the injury the tissues of the wound 
swell, become painful and bluish-green or purple in appear- 
ance. The process extends rapidly and the tissues surround- 
ing the wound become emphysematous; crackling can be 
23 



354 MINOR SURGERY 

elicited by palpation. There is no tendency to the formation 
of a line of demarcation. The patient develops symptoms 
of overwhelming sepsis, high fever, delirium and coma, and 
death often occurs in from twenty-four to forty-eight hours. 
Treatment. — Free incisions may be made in the surrounding 
tissues and antistreptococcic serum administered, but are not 
often of value. If a limb be involved prompt amputation at a 
point well above the infected area is often a life-saving 
procedure. 

Diabetic Gangrene. — The diabetic condition seems to have 
a special tendency to necrotic processes. It seems probable 
that this form of gangrene is due to infection of tissues pre- 
disposed to infection by the presence of sugar and a lessened 
amount of oxygen. This variety of gangrene may be of the 
dry or moist variety. Diabetic gangrene is most frequently 
observed in the feet and legs of elderly people, and a trifling 
injury is apt to be the exciting cause. It may start as 
spreading cellulitis, which eventuates in a moist gangrene. 

As diabetics are bad subjects for operation, preliminary 
treatment of the diabetic condition is of the first importance, 
and operation should be postponed if possible until the 
patient becomes sugar free. If the toes or foot are involved 
amputation above the knee is the most satisfactory operation. 
If done at a lower point the disease is apt to recur in the flaps. 

Embolic Gangrene. — This may follow the lodgment of an 
embolus in an important artery. This itself may be due 
to some infective process, typhoid fever, pneumonia, influ- 
enza, etc. The embolus which causes gangrene probably not 
only occludes the artery, but also vessels of the collateral 
circulation. When an embolus lodges and gangrene occurs 
there is severe pain at the seat of impaction, and there is 
pulsation above, but not below, the seat of the embolus. 
The skin is white and anesthetic, and in thirty-six hours 
becomes purple, green or black, and gradually becomes dry, 
shrivelled and hard, having the appearance of smoked bacon 
skin; in time a line of demarcation forms. Gangrene does 
not extend up to the point of occlusion, but only to a region 
in which the anastomotic circulation is sufficiently active to 
establish a line of demarcation and separation. Moist 



DISEASES COMPLICATING WOUNDS 355 

gangrene is sometimes seen after arterial occlusion by an 
embolus. The sudden loss of the vis a tergo in the arterial 
system, venous reflux and engorgement of the vessels with 
venous blood accounts for its occurrence. A thrombus in an 
artery rarely causes gangrene except in old subjects, as the 
collateral circulation gradually adjusts itself. If gangrene 
occurs it develops slowly and is of the dry variety. 

Treatment. — The limb should be slightly elevated and 
wrapped in cotton, and the area should be dusted with anti- 
septic powders and kept dry. Hot-air baking is often useful. 
Incision of the artery and removal of the embolus has been 
practised, as well as arteriovenous anastomosis. Up to the 
present neither of these procedures has been very satisfactory. 
If there is constitutional reaction supporting treatment should 
be given. If the disease involves the extremities when the 
line of demarcation is well established amputation should be 
done well above this line. 

Presenile Gangrene. — This disease occurs in young male 
adults, and usually involves the legs; first one leg, but in time 
the other leg becomes involved. It is rarely seen in women. 
It starts with severe pain in the toes, foot or leg, and the 
part feels cold. No pulse can be felt in the anterior or 
posterior tibial arteries. If the part is warmed some color 
returns. Walking is painful and difficult from severe pain 
in the calf muscles. If the foot hangs down it becomes red 
or cyanotic. After some months a bleb or ulcer appears upon 
the toes or foot and dry gangrene develops. This does not 
not usually occur until the disease has existed for a year or 
more. It has been ascribed to an obliterative endarteritis 
of all the arteries of the leg. Buerger regards the condition 
as a thrombo-angiitis obliterans of tbe larger arteries and 
deep veins of the leg. It has been attributed to improper 
diet, occupation and excessive use of tobacco and to typhus 
fever. Buerger considers infection the cause. 

Treatment. — A great variety of different methods of treat- 
ment has been employed ; many have failed and others have 
proved only palliative. In the early stage of the disease 
Ringer's solution, 500 cc by hypodermoclysis every other 
day until fifteen or twenty have been given, has been reported 



356 



MINOR SURGERY 



to have given relief of pain and to have arrested the spread 
of the gangrene. Intravenous injection of 2 per cent solu- 
tion of sodium citrate has also been employed. Arterio- 
venous anastomosis has been practised, as well as reversal of 
the circulation by end-to-end anastomosis of the femoral 
vein to the femoral artery. Stratton collected 136 opera- 
tions of this kind in different forms of gangrene which showed 
a direct mortality of 30 per cent and absolute failure in 72 
per cent. 

Sooner or later these cases come to amputation, which 
should be through the tubercle of the tibia or above the 
knee. I amputated both legs in a young man, aged twenty- 
one years, with an interval of a year between the operations, 
with entire relief of pain and improvement in his general 
health. Ten years after the last operation he was well and 
doing laborious outdoor work. 



Fig. 


246. 




^Bg . ■ 


*9-±± 


r M 




iW^mfr 


^^^^^B 




'"*" V ^w 


jyMjJ. H^~ 






* ; \W 


v 


w 2 





Noma following measles; duration one week. (Ashhurst.) 



Noma, Gangrenous Stomatitis, Cancrum Oris. — This is a 
rapidly spreading gangrenous process which begins on the 
mucous membrane of the gums or cheek, but may occur in 
the genitals, noma pudendi or noma vulvae. It occurs in 
children from three to ten years of age, and is apt to follow 
the exanthemata, especially measles. Various bacilli have 
been found by different observers, certain forms of leptothrix 



DISEASES COMPLICATING WOUNDS 357 

being there most frequently present. A mixed infection, 
including saprophytes, almost always exists. The disease 
usually starts upon the mucous membrane of the mouth, 
gums or genitals, and in a few hours a gangrenous ulcer may 
be present. A shiny red spot on the exterior of the cheek 
may be the first thing to attract attention. At an earlier 
stage fetor of the breath may be detected. In a few hours 
the gums or cheek becomes gangrenous and the cheek perfor- 
ated, and a large portion of the jaw bones may become necro- 
tic. I had under my care in the Children's Hospital a child 
with noma of the cheek, who recovered after cauterization, 
and later had all of the necrotic lower jaw removed, except 
one ascending ramus and its condyle. The constitutional 
disturbance is not marked at first, but soon the pulse becomes 
rapid and the temperature elevated, and the patient is apt 
to die of exhaustion, pyemia or septic pneumonia. 

Treatment. — The patient should be given an anesthetic, a 
mouth gag introduced and the gangrenous surface of the 
cheek or gums curetted, and the base and edges thoroughly 
cauterized with nitric acid or acid nitrate of mercury, or the 
Paquelin cautery may be used. If the cheek has been per- 
forated it is better to excise the gangrenous tissue and at 
the same time necrotic portions of the jaw should be removed. 
Similar treatment should be employed in the case of noma 
pudendi or vulvae. The mouth should be frequently washed 
with saline solution or boric solution, and the patient should 
be given stimulants and a nourishing diet. The mortality 
is high, from 70 to 95 per cent. If recovery takes place later 
plastic operations are required for the resulting deformities. 

Tetanus. — This disease is characterized by spasm of the 
voluntary muscles, which invariably results from the infection 
of a wound or focus of infection by the Bacillus tetani. This 
bacillus is anaerobic and is frequently found in the refuse 
from barnyards or stables and in earth or dust. The infec- 
tion may occur in punctured or lacerated wounds, compound 
fractures, ulcers and burns, or through an abrasion of the 
mucous membrane or skin. A wound infected with pyogenic 
organisms or saprophytic bacteria, which being aerobic 
absorb all available oxygen, provides an anaerobic condition 



358 MINOR SURGERY 

favorable for the growth of Bacillus tetani if brought in con- 
tact with it. It is claimed that the Bacillus tetani normally 
infests the intestinal canal of horses and cattle, and has been 
found in the intestines of human beings ingested with 
uncooked food. The occurrence of tetanus after operations 
upon the rectum has been explained by Matas as due to 
contact with feces containing Bacillus tetani. The develop- 
ment of tetanus in wounds received about stables is quite 
common. 

The incubation period of tetanus is about ten days. Cases 
have been reported in which it developed in a few days, and 
others in which it did not appear for a month or longer. The 
duration of the period of incubation is said to be due to the 
distance of the wound from the spinal cord. The disease is 
a pure toxemia. Bacillus tetani may be present in a wound 
without producing any definite reaction, but the toxins they 
produce are alone responsible for the symptoms of the disease. 
Toxins are absorbed directly by the motor nerves of the 
injured part, and are transported by them through the peri- 
neural lymph sheaths to the spinal cord and medulla, and 
becoming fixed in the nerve cells of the spinal cord and 
medulla produce the symptoms of the disease. Toxins 
also enter the circulation, but cannot reach the central 
nervous system except when carried to the peripheral ends 
of motor nerves and absorbed by them. The toxins are said 
to enter into chemical combinations with the nerve tissue. 
The irritation of the motor cord produces tonic contraction 
of the muscles, while irritation of the sensory portion of the 
cord is responsible for clonic convulsions. 

Symptoms. — In acute cases of tetanus, which develops 
within ten days, the patient may complain of pain in the 
wound or chilliness, but he usually first complains of stiffness 
in the jaws and a painful contraction of the extensor muscles 
of the neck. He occasionally complains of spasm of the 
muscles in the region of the wound. The fixation of the jaw 
is known as trismus. In a few hours generalized cramps 
occur, and as a general rule the extensor muscles overcome 
the flexors. The contraction of the muscles of the back is so 
powerful that the patient's body is bent into a curve, so that 



DISEASES COMPLICATING WOUNDS 359 

the entire body is supported on the occiput and the feet 
(opisthotonos) (Fig. 247). If he is bent in the opposite 
direction it is called emprosthotonos, and when lateral deviation 
of spine occurs it is known as pleurothotonos . Tonic spasms 
are more or less continuous, and clonic spasms develop as 
the disease progresses, and arise from peripheral irritations, 
such as exposure to bright light, jarring of the bed, attempts 
at swallowing, etc. The jaws remain persistently stiff and the 
neck arched. The temperature is usually normal but may 
be slightly elevated, and always rises just before death. The 
respiratory movements are rapid and shallow, because of 
muscular rigidity. When clonic spasm involves the thoracic 

Fig. 247. 




Opisthotonos in third day of tetanus. (Ashhurst.) 

muscles cyanosis develops and asphyxia is frequently threat- 
ened in the clonic convulsions. The spasms are very painful 
and extremely exhausting. Retention of urine frequently 
occurs and constipation is marked. Sleep is disturbed by 
the recurring convulsions, and it is difficult to give the patient 
sufficient nourishment. 

The diagnosis is based upon the presence of a wound, 
retraction of the head and stiffness of the jaws, the tonic and 
clonic convulsions and the absence of delirium. The condi- 
tions which may be confused with tetanus are strychnine 
poisoning, hysteria with tetany or hydrophobia. The prog- 
nosis in tetanus is bad. The mortality from tetanus, accord- 



360 MINOR SURGERY 

ing to Jacobson's statistics, is 83.1 per cent for acute cases 
and 43.6 per cent in subacute cases. The longer the period 
of incubation and the longer life is preserved after the symp- 
toms develop, the greater is the probability of recovery. 

Treatment. — The development of tetanus may be prevented 
by the most scrupulous care in treating wounds in which 
tetanus is liable to occur. Septic, punctured and contused 
wounds should be opened, foreign bodies and sloughs removed 
and swabbed with a 3 per cent alcoholic solution of iodine. 
The same application should be made to lacerated wounds: 
1500 units of tetanus antitoxin should be injected into the 
tissues or into any nerves exposed in the wound; this injec- 
tion should be repeated in eight or nine days. The immense 
experience in the use of antitetanic serum during the late 
war has proved its prophylactic value. The efficacy and 
harmlessness of immunizing injections of tetanus antitoxin is 
generally accepted, and it should be employed in all soiled, 
punctured, lacerated and contused wounds. In gunshot 
wounds and those resulting from blank cartridges an injection 
of antitetanic serum of 1500 cc is given when the wound is 
first seen; a second injection at the same amount is given 
at the end of seven or eight days, and at the end of seven or 
eight days more a third injection should be employed. The 
injection is made slowly, and at the second injection the 
patient should be watched for the slightest sign of anaphy- 
laxis; if this is noted the injection should be promptly 
stopped. 

The treatment recommended by Ashhurst is as follows: 
When the disease has once developed active treatment should 
be promptly instituted. The principles of treatment accord- 
ing to Ashhurst are : (1) To remove the source which supplies 
the toxin (i.e.) bacilli which are still in the wound; (2) to neutra- 
lize the toxins already formed; (3) to depress the functions of 
the spinal cord; and (4) to sustain the patient by nourish- 
ment. The patient should be isolated in a quiet, cool, dark- 
ened room, and a special nurse should be placed in charge. 
The dressing of the wound should be that employed for the 
prevention of tetanus. The toxins should be neutralized by 
injections of antitoxin into the subarachnoid space. It was 



DISEASES COMPLICATING WOUNDS 361 

pointed out by Ashhurst and John that, used in this way, it 
acts directly upon the nerve roots, and that repeated intra- 
spinal administration has been followed by immediate and 
favorable effects. 

Anesthesia is not necessary, but often desirable. If 
employed chloroform is better than ether. 

Spinal puncture is made with a hollow needle between the 
second and third lumbar spaces, and a few cubic centimeters 
of the subarachnoid fluid removed, and from 3000 to 10,000 
units of antitoxin, diluted with warm saline solution, are 
slowly injected by syringe or gravity. If the site of inocula- 
tion is on the upper extremity or head, the foot of the table 
may be raised to allow the antitoxin to gravitate toward the 
medulla. If no marked improvement follows the subarach- 
noid injection within six or eight hours, 18,000 to 20,000 units 
of antitoxin should be administered intravenously. The 
intraspinal and intravenous injections should be repeated 
daily until the disease is definitely controlled. Since the 
adoption of intraspinal therapy there has been less reason for 
intravenous injections; all the nerves may be reached simul- 
taneously by the spinal route. 

To depress the function of the spinal cord drugs may be 
given by the mouth if the patient can swallow, or by the 
rectum; hypodermic administration is best when possible. 
These drugs should be administered in doses sufficient to 
produce some effect. Ten to 20 grains of chloral hydrate 
and 20 to 40 grains of bromide of potassium should be given 
as often as every two or three hours; more should be given 
if the patient requires it, and less if it proves sufficient to 
relieve the pain and diminish the rigidity. Chloretone has 
given gratifying results in doses of 30 to 60 grains admin- 
istered by the mouth or rectum, dissolved in whiskey or hot 
olive oil. 

Nursing of the patient is very important. Clear the bowels 
by a brisk purge early in the disease. Watch for retention of 
urine; guard against bed sores. Enforce feeding by the 
stomach tube, passed under a general anesthetic if necessary. 

Cephalic Tetanus. — This is a rare form of tetanus, sometimes 
called hydrophobic or head tetanus. It follows head inju- 



362 MINOR SVRGERY 

ries and the muscular contractions are confined to the face, 
neck and pharynx, although the abdominal muscles may 
also be rigid. There may be paralysis of the facial nerve, the 
oculomotor or the hypoglossal nerve, or there may be no 
paralysis. The treatment is similar to that employed for 
acute tetanus. 

Chronic Tetanus. — This disease develops from ten days to 
several weeks after a wound. The symptoms are less severe 
than in acute tetanus. The muscular spasm is widespread, 
but it may not be persistent. Intervals of relaxation occur 
which permit the patient to sleep and take nourishment. 
The disease may last for weeks. Chronic tetanus had a 
mortality of 40 to 50 per cent, but under modern methods of 
treatment it is claimed that it has been reduced to 35 to 50 
per cent. 

REMOVAL OF FOREIGN BODIES. 

Foreign bodies may enter the body through the normal 
openings or by means of wounds. The location of these 
bodies may be made by palpation, a probe or by a roentgen- 
ray examination. 

Foreign Bodies in the Urethra. — These are generally intro- 
duced into the urethra for purposes of sexual excitement and 
often slip from the grasp of the individual and pass within 
the meatus or into the bladder. If lodged in the urethra 
they may be removed with delicate forceps, firm pressure 
being made upon the base of the penis to prevent it slipping 
into the bladder. A pin lodged in the urethra with its point 
toward the meatus may have its point pushed through the 
urethra and skin, and being reversed the head may be made 
to present toward the meatus when it can be removed with 
forceps or by manipulation. Pins, needles, pencils, hair-pins 
and many other objects are often removed from the urethra. 

Foreign Bodies in the Bladder. — If there is doubt as to 
the nature of the foreign body in the bladder a cystoscopic 
or roentgen-ray examination should be made. In the male 
a small body may be grasped with a lithotrite and crushed 
and removed or may be removed without crushing. In the 
female dilatation of the urethra will often permit the intro- 



REMOVAL OF FOREIGN BODIES 363 

duction of the female urethroscope and inspection and 
removal of the body with forceps. If the body is irregular 
in shape or is encrusted with urinary salts it should be 
removed through a suprapubic incision into the bladder. 

Metallic rings are sometimes slipped over the penis, or 
strings may be tied lightly around the organ, and if they fit 
tightly the resulting congestion quickly swells the glans and 
tissues beyond the ring so that it becomes buried and it is 
impossible to remove it. If the constriction is not promptly 
removed gangrene results. A flat director should be care- 
fully passed under the ring to prevent injury of the skin, and 
it should be divided at one or two points by a file or small 
steel saw, when it can be removed without difficulty. Strings 
can be removed by cutting them. 

Foreign Bodies in the Rectum. — These may consist of 
objects introduced into the rectum to excite sexual feeling or 
to assist in defecation, or masses of fecal matter may be 
allowed to remain in the rectum until they become so firm 
that they require the same treatment for their removal as 
foreign bodies. Hard fecal masses may sometimes be grasped 
with forceps and removed or be broken up with the finger, 
and removed by the finger or by a stream of water. It is 
usually well after locating the position of the foreign body to 
anesthetize the patient and dilatate the sphincter muscle. 
The body can then be removed with the finger or forceps. 
If the body is irregular in shape a speculum may be intro- 
duced or the body may have to be broken or cut into frag- 
ments before it can be removed. Care should be taken to 
do the least possible damage to the rectal mucous membrane 
in order to avoid infection. 

Impaction of the Rectum. — This condition often occurs in 
cases of severe illness when a milk diet is used and is fre- 
quently observed in aged subjects suffering from fractures 
which confine them to bed. The condition is frequently 
overlooked as the impacted mass produces enough irritation 
to cause frequent thin fecal evacuations which escape around 
the mass. The patient complains of frequent bearing-down 
pains with rectal tenesmus and the escape of slight watery 
stools and is usually credited with having diarrhea. These 



364 MINOR SURGERY 

symptoms with the absence of formed stools are significant 
of impaction of the rectum. 

Digital examination of the rectum reveals a firm, putty-like 
mass which may be as large as the closed fist. 

Treatment. — This consists in introducing the finger and 
breaking up the fecal mass, or introducing a speculum and 
removing the mass with a dull curette, and giving rectal 
enemata until the rectum is clear of fecal matter. 

Foreign Bodies in the Vagina. — Foreign bodies are fre- 
quently introduced into the vagina to produce sexual excite- 
ment, or they may consist of bodies introduced to prevent 
uterine displacement. Pessaries often are found whose 
presence had been forgotten by the patient. If the body 
becomes buried in the vaginal walls difficulty in urination 
and purulent discharge are the prominent symptoms. The 
vagina should first be irrigated and an antiseptic solution and 
a speculum introduced to locate the position of the body. 
Neglected pessaries can usually be removed without diffi- 
culty, but if embedded for a long time it may be necessary 
to divide them at one or two points with cutting forceps. 
They can then be removed with forceps, care being taken to 
do the least possible damage to the vaginal walls. 

Foreign Bodies in the Pharynx. — Small foreign bodies, such 
as pins, fish bones, pieces of bone, pieces of straw, jack 
stones, etc., may become lodged in the pharynx and soon 
become embedded by swelling of the mucus membrane. 
The sensation of the patient will often assist in locating the 
position of the body. 

The pharynx should be inspected with the aid of reflected 
light and explored by the finger. When the body is located 
it can usually be removed with forceps. I have seen a jack 
stone embedded behind the larynx, which was removed with 
great difficulty. 

Foreign Bodies in the Esophagus. — Foreign bodies may be 
arrested at any point of the esophagus; but are apt to lodge 
opposite the cricoid cartilage or near the cardiac orifice of the 
stomach. A great variety of objects have been found lodged 
in the esophagus — coins, buttons, pieces of bone or meat, pins, 
safety pins and plates with artificial teeth, etc. The body 



REMOVAL OF FOREIGN BODIES 365 

should be removed as soon as possible to prevent ulceration 
and perforation of the esophagus. A soft, smooth body may 
be dislodged and pressed downward into the stomach with a 
bougie. The body may be located and removed by the use 
of Jackson's esophagoscope and forceps. If, however, the 
body is of considerable size and irregular in shape like a 
tooth plate it is better to remove it by operation, external 
esophagotomy; if low down in the esophagus it may be 
necessary to perform thoracic esophagotomy. 

Foreign Bodies in the Stomach. — Bodies which have 
entered the stomach often pass into the intestines and escape 
from the rectum. If the body is of such a shape that it is apt 
to be arrested in the stomach or intestines it should be located 
by a roentgen-ray examination and should be removed by 
gastrotomy. 

Foreign Bodies in the Intestines. — Bodies usually pass 
with great facility through the intestinal tract and escape 
from the rectum. Purgatives should not be given; rather a 
diet which produces an increase in the bulk of the fecal 
matter. Intubation tubes are frequently swallowed and pass 
without difficulty. A roentgen-ray examination taken at 
intervals will show the change in the position of the body in 
the intestinal tract. 

If arrested at any point and symptoms of obstruction are 
present it should be removed by abdominal section and 
enterotomy. 

Foreign Bodies in the Trachea and Larynx. — Bodies lodged 
in the larynx and trachea produce violent coughing effects 
and soon dyspnea develops. The bodies most commonly 
found are grains of corn, seeds, pins, safety pins and frag- 
ments of bone. They are often dislodged by coughing and 
expelled. They may be removed by using the laryngeal 
mirror and forceps or by the use of Jackson's laryngoscope 
and forceps. If the dyspnea is urgent tracheotomy should 
be performed and the body removed through the tracheal 
wound or later by tracheal forceps. 

Foreign Bodies in the Bronchi. — A foreign body which has 
passed below the trachea usually lodges in one of the larger 
divisions of either bronchus, usually the right bronchus. If 



366 MINOR SURGERY 

the breathing is much embarrassed a low tracheotomy should 
be performed and the body may be grasped with forceps 
through the tracheal wound and removed. Bronchoscopy by 
Jackson's method has been used successfully for the removal 
of bodies impacted in the bronchi (p. 193). 

Foreign Bodies in the Eye. — Bodies such as particles of 
sand, cinders, fragments of steel often lodge in the eye, and 
may be adherent to the conjunctiva or embedded in the 
cornea. The eye should be inspected with a good light and 
the lids turned if necessary. 

The body may be removed if in the conjunctiva or cornea 
by touching it with a wisp of cotton twisted on a probe or 
match stick, if embedded in the cornea a few drops of a 2 
per cent solution of cocaine should be dropped into the eye 
and the body removed with an eye spud. 

If the body has penetrated the cornea the case should be 
referred to a specialist. 

After removing the foreign body the eye should be fre- 
quently douched with boric acid solution. 

Foreign Bodies in the Nose. — Foreign bodies, such as peas, 
grains of corn, beans, buttons, beads and pencils are often 
introduced into the nasal canals, especially by children. 
Their presence often causes no marked symptoms, but if 
ulceration takes place, purulent and blood-stained discharges 
occur; a persistent unilateral nasal discharge in a child should 
always suggest the possibility of an impacted foreign body. 
The body may pass backward and lodge in the nasopharynx. 

A dry body, like a pea or bean, may absorb moisture and 
swell so that it becomes very firmly imbedded; the impac- 
tion in all cases becomes firmer from the swelling of the 
surrounding mucous membrane. It is well to give an anes- 
thetic before attempting to remove foreign bodies from the 
nose. 

The nasal cavity should be inspected through a speculum 
and the body grasped with forceps and removed; a small 
curette is sometimes useful. When the body is in the naso- 
pharynx the removal is very difficult. A mouth gag should 
be used and the finger should be passed into the nasopharynx 
from the mouth when by manipulation and forceps it may 



CARBUNCLE 367 

easily be removed by way of the nasal cavity or by the naso- 
pharynx. An antiseptic spray should be used after the 
removal of the body. 

Foreign Bodies in the Ear. — Hardened wax, beads, seeds 
and insects are often found in the ear. These may be 
removed by syringing the ear with warm water, and if this 
fails to remove them their removal may be accomplished by 
delicate angular forceps, with which the body is grasped. 
Live insects may be killed by dropping a little olive oil in 
the ear, and they then may be removed by syringing the ear 
with warm water. 

FURUNCLE OR BOIL. 

This consists of a localized inflammation oi the true skin 
and subcutaneous cellular tissue. The infection is caused 
by the entrance of the Staphylococcus pyogenes aureus 
through a hair follicle or sebaceous gland, and gives rise to 
limited tissue necrosis. A hard papule surrounded by indu- 
ration appears upon the skin and gradually increases in size 
and may soften in the center and open, discharging a few 
drops of pus and a small mass of necrotic tissue known as 
a core. 

Treatment.— In the early stages of the affection, steriliza- 
tion of the area may be accomplished by first injecting a few 
drops of a 2 per cent novocaine solution into the center of 
the inflammatory mass, and introducing a red hot needle into 
the hair follicle or sebaceous gland; or the central soft spot 
may be incised and a match stick, tooth pick or swab satur- 
ated with carbolic acid may be bored into the softened tissues. 
If these procedures fail to arrest the spread of the infection 
excision or circular incision around the indurated area should 
be made and a dressing of dichloramine-T applied. In cases 
of recurrent furuncles an autogenous vaccine may be used 
with good results. 

CARBUNCLE. 

This is an inflammation of the skin and subcutaneous tis- 
sues with multiple foci of necrosis arising from an infection 
of the hair follicles, the causative organism being the 



368 



MINOR SURGERY 



Staphylococcus pyogenes aureus. The most common sites of 
this affection are the skin of the back of the neck and of the 
upper part of the back, but it may occur on other parts of the 
body, the lips, face, thighs and trunk (Fig. 248). 

Carbuncle should be regarded as a serious affection in 
debilitated subjects and those suffering from diabetes and 
nephritis. I have seen a number of fatal cases in diabetics. 
Carbuncle of the upper and lower lip is occasionally observed 
and is considered especially dangerous from the risk of infec- 
tive thrombosis of the venous sinuses of the brain. 

Fig. 248. 




Carbuncle of the neck in a diabetic. 



Warren explains the spread of the infection in carbuncle 
by the fact that the hair follicles extend only a short distance 
into the true skin; columns of fatty tissue (columnar adiposae) 
run from the subcutaneous tissue in an oblique position to 
join the point and sides of the hair follicle and each contain 
a sweat gland. When pus forms it runs down one of the 
columns and works its way to the deeper tissues and from 
one to another interspace and finds its way to the surface by 
other fatty columns. Thus, numerous foci of pointing appear 
over the surface of the carbuncle. 



CARBUNCLE 369 

Symptoms. — An inflammatory area appears at the site of 
infection; a papule develops with an indurated base; the 
latter spreads rapidly and in a few days a number of pustules 
appear over its surface, each pustule marking the site of a 
focus of necrosis. At the beginning of the infection there may 
be a chill, and there is always fever and pain. In a few days 
some of the pustules rupture and necrotic tissues may be 
discharged. The induration ceases to spread and the case 
progresses slowly toward a cure. In other cases the tissues 
being honeycombed with areas of necrotic tissue, infection 
spreads, extensive sloughing of the tissues occurs, and if the 
patient does not succumb from hemorrhage or infection 
recovery may follow after many weeks. 

Treatment. — The patient should be given supporting treat- 
ment — nourishing food, tonics and stimulants — and if he is 
also suffering from diabetes or Bright's disease appropriate 
treatment for these affections should be administered. 
Crucial incisions through the indurated tissues was formerly 
practised, followed by the application of hot antiseptic dres- 
sings; but in spite of these the infection often continued to 
spread. The Carrell-Dakin treatment should be used after 
incisions have been made. I have also seen favorable results 
follow dichloramine-T dressings. 

The treatment which is now considered most effective in 
carbuncle in favorable locations, is complete excision of the 
indurated tissue and packing the wound loosely with strips 
of gauze saturated with dichloramine-T. If hemorrhage is 
free vessels should be tied where possible, or packing of the 
wound should be employed. It is surprising how rapidly 
these extensive wounds heal; skin grafting may also be 
employed to hasten healing when the surface of the wound is 
in condition for grafts. In carbuncles of the face and lips 
excision is not applicable; here incisions planned to avoid 
important structures should be employed and subsequent 
dressings with dichloramine-T applied. If the upper lip be 
involved, free longitudinal incisions down to the mucous 
membrane should be made and if the spread of infection is 
not arrested by these incisions, the facial vein should be 

24 



370 MINOR SURGERY 

ligated to prevent infective thrombosis of the lateral sinuses 
of the brain. 

Vaccine Treatment. — In patients who have a succession of 
boils or carbuncles or multiple infections, vaccination with 
an autogenous vaccine of the causative organism or a mixed 
vaccine may be employed with good results. 

VARICOSE VEINS. 

This is a condition in which the veins become elongated, 
dilated, tortuous and pouched. This may affect the super- 
ficial or deep veins, in any part of the body. The veins of the 
lower extremities, especially the saphenous veins, are those 
most frequently involved. The cause is said to be a predisposi- 
tion to the growth of vein tissue which leads to valve failure, 
and regurgitation of the blood from the deep veins into the 
superficial venous channels. Varicose veins develop during and 
after pregnancy, and in those who stand on their feet for long 
periods and in those who make great muscular efforts. The 
valves become incompetent, the blood stagnates, hypertrophy 
and sclerosis of the vessel walls occur and thrombosis may 
finally obliterate the diseased vein. The most prominent 
symptoms in varicose veins of the lower extremities are pain, 
thickening of the perivascular tissue and edema. Poor nutri- 
tion of the skin may upon slight injury produce an abrasion 
which fails to heal and varicose ulcer results. On the other 
hand, one sees many subjects who have well-developed vari- 
cose veins who present no disabling symptoms and are 
actively employed in laborious work. A varicose vein may 
rupture externally and give rise to profuse hemorrhage, 
which is easily controlled by pressure — a compress fixed 
over the wound by a bandage. Rupture of a deep vein 
causes sudden sharp pain followed by extensive ecchymosis. 
The palliative treatment should always be tried first, and 
consists in emptying the veins and reducing the edema 
by elevating the limbs and applying an elastic bandage 
or elastic stocking. These appliances give temporary relief 
and prevent further dilatation of the veins. The operative 
treatment should be considered when palliative measures 



ULCERS 371 

fail to give relief. If varicosity of the superficial veins 
results from thrombosis of the deep veins and edema exists, 
ligation or excision of superficial veins should not be under- 
taken, as its performance might cause permanent edema. 
If elastic support with obliteration of the varicosities gives 
relief it shows that the collateral circulation is efficient. The 
operations for the cure of varicose veins are not unattended 
by risk. Schede's operation is sometimes done, which con- 
sists in a circular incision of the tissues below the knee down 
to the deep fascia, dividing ail of the superficial veins; both 
ends of the denuded veins are ligated and the wound is closed 
with sutures. This operation has the disadvantage that it 
divides also the superficial lymphatic and sensory nerves, 
and may be followed by edema, paresthesia or neuralgia 
or trophic changes in the skin. Trendelenburg's operation 
has furnished a fair number of recoveries. It consists in 
exposing the saphenous vein by an incision just below the 
saphenous opening and dividing the vein between two liga- 
tures, the object being to break the column of blood, thus 
relieving pressure symptoms. The saphenous vein may be 
removed by one long incision, or it may be removed by a 
number of incisions by subcutaneous tunneling of the skin. 
Multiple phlebectomy is considered by some surgeons the 
most satisfactory operation. It consists in removing sections 
of the vein from 7 to 10 cm. in length at the saphenous open- 
ing and other parts of the thigh and leg, where the main 
trunks or their branches are most dilated. The intervening 
portions become thrombosed, contract and produce no further 
symptoms. 

ULCERS. 

An ulcer is a loss of substance due to molecular death of 
the superficial tissues which results from bacterial infection. 
Repair of ulcers occurs by granulation and cicatrization. 
When an ulcer is healing the discharge of pus diminishes, the 
edges become firmer and granulations appear upon its surface. 
At the edges of the ulcer the epithelium proliferates, gradually 
covering the granulations; the fibroblasts become converted 
into white fibrous connective tissue and the surface of the 



372 - MINOR SURGERY 

ulcer contracts, decreasing the area, which must be covered 
by the surrounding epithelium. 

Simple or Healthy Ulcer. — The tendency of this ulcer is to 
heal. The best example of this ulcer is that following super- 
ficial incised wounds or burns; it may heal under a scab. 
Protection of the surface of the ulcer from injury by a dressing 
of lint spread with boric acid ointment and a few layers of 
gauze is the only dressing required. 

Inflamed Ulcer. — This form of ulcer may present active, 
inflammatory symptoms from the start, or they may occur 
in a healthy ulcer from local irritation or from constitutional 
causes. It often develops in drunkards or debilitated sub- 
jects whose resistance is low. The tissues surrounding the 
ulcer are red and inflamed, the surface of the ulcer is covered 
by grayish sloughs, the discharge becomes thin and irritating 
and pain is a prominent symptom. The formation of sloughs 
indicates that the tissue death is progressing rapidly. When 
the ulcer spreads with great rapidity and becomes deeper and 
of greater surface area it is known as a phagedenic ulcer. 

Treatment. — The patient should be confined to bed and 
given calomel or blue mass, followed by a saline. The limb 
should be elevated and surface surrounding the ulcer painted 
with tincture of iodine and alcohol, equal parts. Hot anti- 
septic should be applied to the surface of the ulcer and 
changed frequently. Dichloramine-T dressing or Carrel- 
Dakin treatment may be used with advantage. Under this 
treatment the inflammatory symptoms often subside rapidly 
and the ulcer assumes a healthy appearance, when the 
dressings for a healthy ulcer may be applied. 

Edematous or Weak Ulcer. — This presents large flabby 
granulations of low vitality and easily detached from the 
surface of the ulcer. This condition results from improper 
dressing or the prolonged use of poultices or wet dressings. 
The granulations should be cauterized with pure carbolic 
acid, or the solid stick of nitrate of silver, or may be cut away 
with scissors. The surface should next be dressed with 
stimulating ointments, scarlet red (8 grains) to vaseline (1 
ounce), used only for a few days and followed by ichthyol 
ointment, balsam of Peru or 25 per cent argyrol solution. 



ULCERS 



373 



Irritable Ulcer. — This is usually small and situated near 
the ankle, or over one of the malleoli. The surrounding skin 
is thickened, there is little discharge and its surface is glazed 
and extremely painful. The condition is probably due to 
exposure of sensory nerve filaments of the musculo-cutaneous 
or internal saphenous nerves. The patient should rest in 
bed with the foot elevated, and the surface of the ulcer should 
be touched with the solid stick of nitrate of silver or carbolic 







Fig. 249. 






^^^ 




s • K 1 

B ] 

1 1 B ] 
mm 

■ m I 

<j 1 1 « " 

BBB •' •• . 
: H H m 

1 B . 






-^ 


I PHB 1 




1 • ^■«a J ?gS| 




^"■^■" , 






■m^^hsi 





Irritable ulcer. (Ashhurst.) 



acid, or the application of a 20-gr. solution of chloral hydrate 
may temporarily relieve the pain. This should be followed 
by a boric ointment dressing. If this treatment fails to give 
relief the affected nerve may be divided from 2 to 3 inches 
above the ulcer. 

Indolent or Callous Ulcer. — This is one of the commonest 
forms of leg ulcer. It occurs in adults on the lower portion 
of the leg over the tibia or fibula. The surface of the ulcer is 
comparatively dry, the granulations are poorly developed 



374 



MINOR SURGERY 



and the edges of the ulcer are indurated, giving the surface of 
the ulcer a concave appearance. This form of ulcer usually 
develops after a slight injury, a contusion, scratch or abrasion 
which receives no attention, in patients who are compelled 
to be on their feet from their occupation, and who often 
present edema of the limbs from poor circulation of blood and 
lymph in the parts. 

Fig. 250. 




Indolent or callous ulcers. (Ashhurst.) 



Treatment. — If a patient with indolent ulcer is put to bed, 
attention paid to the condition of the bowels and kidneys, 
the leg elevated and wet antiseptic dressing applied the ulcer 
is soon converted into one of a healthy type, and healing 
occurs. As many patients with this type of ulcer cannot 
afford to stop their work, it is important to apply a dressing 
which will allow them to continue their work during the 
course of treatment. The most satisfactory dressing for these 
cases is strapping with resin or Z. O. adhesive plaster, and 
support of the tissues of the foot and leg to the knee by a 



ULCERS 



375 



well-applied muslin bandage. If possible it is well to keep 
the patient at rest for a few days, and apply warm antiseptic 
fomentations, which diminish the induration surrounding the 
ulcer. The surface of the ulcer may be dressed for a day or 
two with ointment of scarlet red (gr. viij), boric acid (gr. xx), 
petrolatum (§j), and the skin surrounding the ulcer should be 

Fig. 251. 






Strapping an ulcer of the leg. 



sponged with alcohol. Straps of resin plaster or Z. O. adhe- 
sive plaster 1J to 2 inches wide, and long enough to extend 
two-thirds of the distance around the limb, are required. If 
the portion of the limb is covered with hairs it should be 
shaved before the straps are applied. The surface of the 
ulcer should be touched with a solution of nitrate of silver 



376 



MINOR SURGERY 



(15 grs. to water 1 oz.) and the surrounding skin dried. The 
first strap being heated, if resin plaster is used, it is applied 
transversely to the long axis of the leg and carried two-thirds 
of the distance around the limb. Care should be taken to 
see that the straps are so applied as not to cover the entire 
circumference of the limb, as by so doing edema and injurious 



Fig. 252. 





Strapping an ulcer of the leg. 

circular compression might result. Another strap is applied 
to a corresponding point of the skin above this one, so that 
it overlaps one-third of the strap first applied, and is carried 
two-thirds of the way around the limb. Additional straps 
are then applied until the ulcer is covered in, and the straps 
are carried several inches above the ulcer. 



ULCERS 377 

Strapping of ulcer of the leg may also be accomplished by 
using straps of plaster 1 J inches in length. The ends of two 
straps are placed upon each side of the limb some distance 
below the ulcer and the straps are brought up and made to 
cross each other so as to draw the tissues toward the point 
of crossing. A number of imbricated straps are applied in 
this way until the ulcer and surrounding tissues are covered 
in and supported (Fig. 252). A muslin bandage 2J inches 
in width is next firmly applied from the base of the toes to 
the knee. The patient returns in a few days or a week, the 
straps are removed, the skin cleansed with alcohol and the 
the ulcer touched with silver solution, and the strapping is 
reapplied in the same manner. The patient returns at 
intervals of a week until the ulcer is healed. Chronic ulcers 
in other parts of the body may be strapped in the same 
manner. It is surprising to see how rapidly ulcers heal 
under this method of dressing which have often existed for 
years. 

After the ulcer is healed the patient should wear an elastic 
webbing bandage for some time. He soon learns to apply 
this to furnish the proper amount of support. In some cases 
in which repair is slow in spite of treatment radiating inci- 
sions through the indurated edges of the ulcer may be made 
with advantage. 

Varicose Ulcer. — This ulcer is associated with varicose 
veins of the leg. Varicosity of the veins causes stagnation 
of blood. This impairs nutrition and a slight traumatism in 
this area of impaired nutrition becomes infected and ulcer re- 
sults (Fig. 253). A slight traumatism in this form of ulcer is 
often followed by profuse hemorrhage. Rest in bed with ele- 
vation of the leg, and the application of an ointment of ichthyol 
or boric acid will often be followed by a prompt cure. If the 
patient cannot go to bed he may be treated as a walking 
case. The ulcer and surrounding skin are cleansed, the 
surface touched with a solution of nitrate of silver and 
strapping and a supporting bandage applied, as used in the 
treatment of indolent ulcers. After the ulcer is healed if he 
wears an elastic webbing bandage to support the varicose 
veins the ulcer is less likely to recur. In persistent cases 
excision of the neighboring varicose veins may be practised, 



378 MINOR SURGERY 

but this should not be done in the presence of active phlebitis; 
or if the veins are thrombosed the excision should be done at 
a point where this condition is not present. 

Fig. 253. 




Varicose ulcer of leg. (Ashhurst.) 

Syphilitic Ulcers of the leg are usually situated above the 
middle of the leg, and may be associated with disease of the 
underlying bone. These ulcers respond promptly to anti- 
syphilitic treatment, and the local application of an ointment 
of iodoform or calomel. 

Warty Ulcer, known also as the ulcer of Margolin, is one 
which develops upon a scar of a wound of the soft parts or 
bone or a burn, many years after the injury has been received. 
The surface of the ulcer presents fine wart-like granulations, 
and the discharge from the surface is free and very offensive. 
This form of ulcer is malignant, and when it involves an 
extremity, amputation is the safest treatment. 



PART III. 
ASEPSIS AND ANTISEPSIS. 



SURGICAL BACTERIOLOGY. 

Bacteriology is the science of microorganisms. The 
discovery and study of these organisms in recent years has 
revolutionized surgical practice. 

The microorganisms associated with disease in man are 
bacteria, spirochetes, certain yeasts and moulds, filamentous 
fungi and protozoa. In addition to these varieties there is 
a group of disease-producing organisms which have never 
been isolated. The causative agent is known as a filtrable 
virus, because it is able to pass through the pores of a filter too 
small to allow passage of known bacteria. Almost all infec- 
tious diseases may under certain circumstances possess surgi- 
cal importance, but practically, surgery is concerned chiefly 
with bacteria. 

Bacteria are minute unicellular organisms representing the 
lowest order of plant life. They are classified primarily 
according to their shape into: (1) The cocci or round organ- 
isms; (2) the bacilli or straight rod-shaped organisms; and 
(3) the spirilla or curved rod forms. Only a comparatively 
small number of known varieties of bacteria are capable of 
producing disease. These are known as the pathogenic 
bacteria. Organisms which are incapable of producing disease 
are known as non-pathogenic bacteria or saprophytes. Many 
of these bacteria are most useful, such as the nitrifying bac- 
teria which abstract nitrogen from the air, thus enriching the 
soil. Fermentation and putrefaction are the result of micro- 



380 ASEPSIS AND ANTISEPSIS 

organismal action and in fact it was the investigations of 
Pasteur concerning the cause of spoilage of wines and beers 
that laid the foundation of modern bacteriology. 

Koch's Law. — To prove that a certain bacterium is the 
cause of a disease, the following rules have been laid down by 
Koch: (1) The bacterium must first be found in the diseased 
person or animal; (2) it must be cultivated outside of the 
body; (3) when inoculated in pure culture in a healthy animal 
it must produce the original disease; (4) from the body of the 
animal the original microbe must be capable of again being 
isolated. 

Bacteria multiply by the simple process of division, which 
under favorable circumstances may occur with incredible 
rapidity. Fisher has stated that the colon bacillus and the 
spirillum of cholera may divide in about twenty minutes. 
If this rate of multiplication could be maintained it is easily 
calculated that a single organism would have about sixteen 
hundred trillion descendants in twenty-four hours. Lack of 
food and other inhibitive influences tend to prevent such 
excessive rates of multiplication. Many bacteria are motile, 
being able to propel themselves through fluid by means of 
whip-like prolongations known as flagella. Non-motile organ- 
isms have no such method of locomotion, but are transferred 
passively by wind, water or moving objects. 

The study of bacteria is made possible by the microscope 
and the development of special technical methods whereby 
they may be artificially cultivated and isolated in pure cul- 
ture and their characteristics noted. Certain dyes are 
employed to stain bacteria in order to make them more 
easily visible under the microscope and to reveal their finer 
structure. Common stains employed for this purpose are 
methylene blue, gentian violet and carbol-fuchsin. The 
majority of bacteria are able to multiply in the presence of 
atmospheric oxygen which they employ in their metabolic 
processes very much as the higher plants and animals. Such 
bacteria are known as aerobes. Certain other bacteria can 
thrive only when oxygen is excluded, and these are known as 
anaerobes. Many varieties are able to multiply under both 
conditions, being known as facultative aerobes or anaerobes. 



SURGICAL BACTERIOLOGY 381 

Spores. — An interesting phenomenon of great practical 
importance is the formation by certain bacteria of what are 
known as spores. These are round or oval bodies, developed 
in the substance of the bacteria and apparently represent a 
resting stage. These spores are much more resistant to 
sterilizing agents of all varieties than the growing or vegeta- 
tive form of the organism. According to Hiss and Zinsser, 
a 10 per cent solution of carbolic acid will kill the vegetative 
forms of anthrax bacilli within twenty minutes, but anthrax 
spores are able to resist the same disinfectant for a much 
longer period in a concentration of over 50 per cent. Although 
the vegetative forms of the same bacilli are killed at once by 
live steam, the spores will withstand its action over ten to 
fifteen minutes. Whenever the spores of a microorganism 
are put into a suitable environment as to temperature, moist- 
ure and food, the spores will develop into vegetative forms 
which then multiply by division in the ordinary manner. 
Important examples of sporulating forms are the tetanus 
bacillus and the gas bacillus. Methods of preparing surgical 
materials in order to be safe must kill spores as well as the 
vegetative forms. 

The bacteria of greatest importance surgically are the 
Staphylococcus albus, Staphylococcus aureus, Streptococcus 
pyogenes, pneumococcus, gonococcus, the colon and typhoid 
bacillus, the pneumobacillus, tetanus bacillus, gas bacillus 
(Bacillus aerogenes capsulatus), tubercle bacillus, diphtheria 
bacillus and the Bacillus pyocyaneus. The spirochete of 
syphilis possesses great surgical importance. Of the diseases 
due to the higher bacteria, actinomycosis due to actinomyces 
is the most important. Rare instances of ulcerations and 
occasional generalized infections due to yeasts or blastomy- 
cetes are reported, and moulds occasionally produce lesions of 
the mucous membranes, the most common and best known 
of which is the disease, thrush, due to the Oidium albicans. 
Diseases due to flltrable virus, such as hydrophobia, small- 
pox and typhus fever only rarely possess surgical significance, 
with the exception of anterior poliomyelitis or infantile 
paralysis, which is the most important in this connection 
because of the paralyses and deformities which result from it. 



382 ASEPSIS AND ANTISEPSIS 

Pathogenic Action. — Bacteria produce disease by the form- 
ation of toxins or poisons which damage the tissues of the 
host. These toxins may be excreted by the bacteria and 
conveyed in soluble form by the blood and lymph, thus affect- 
ing regions at a distance. These are known as exotoxins. 
Other toxins are the result of decomposition of the bacteria 
themselves and are not set free until the organism dies and 
undergoes solution. These are endotoxins. Lodgment and 
multiplication of bacteria at any point within the body pro- 
duce inflammation which is Nature's defense reaction. The 
phenomena of infectious diseases are the result of such local 
damage plus the general or systemic reaction to the absorbed 
products of the infection. 

A sterile wound is one in which no microorganisms are 
present. This constitutes complete asepsis and is the aim of 
surgical technic in so-called clean operations carried out upon 
non-infected tissues. It is not always possible to obtain 
absolute asepsis, but the presence of a few microorganisms 
derived from the skin or air will not prevent the wound from 
healing without inflammation or suppuration. Formerly the 
air was thought to be an important avenue in the conveyance 
of infection to wounds, but it is now known that the bacteria 
carried in the air are usually non-pathogenic and not numer- 
ous, unless the air is in violent motion and carries along with 
it obvious particles of dust and dirt. It is possible, therefore, 
to operate with practical immunity from infection by employ- 
ing a technic which permits no contact of unsterile or con- 
taminated objects or materials of any kind with the fresh 
uncontaminated tissues of the wound, since for all practical 
purposes it is only by this means that clean wounds become 
infected. 

Contamination means the soiling of clean tissues by micro- 
organisms or substances which are carriers of bacteria. Every 
article and material of any sort whatever, which has not been 
previously sterilized and maintained in a sterile condition 
must be regarded as a potential source of contamination. 

Infection is the state or condition which results from con- 
tamination and lodgment of pathogenic microorganisms 
within the tissues. There is a certain latent period between 



SURGICAL BACTERIOLOGY 383 

contamination and the onset of inflammation or disease during 
which time mechanical cleansing of a wound may obviate 
infection. In the recent war this mechanical disinfection 
was widely practised, with the most beneficial results. The 
method consisted of complete removal of contaminated sur- 
faces, devitalized tissues and foreign material, and was known 
as " debridement." This state of contamination for practical 
purposes may be considered to have terminated at the end of 
about eight hours. After this time the lodgment and multi- 
plication of bacteria has occurred and the phenomena of 
inflammation have begun. This is the stage of infection, and 
mechanical efforts at removal of the infection are of no value 
and often dangerous. Bacteria may gain entrance into the 
body through any wound or abrasion of the skin or mucous 
membrane, or in certain instances make their way unaided 
through the integuments. Not infrequently they get into 
the lymph vessels or into the blood stream and are trans- 
ported to distant regions. The point of entrance is known 
as the portal of entry and may be very insignificant in 
comparison with the results. 

The role of insects in the spread of infective agents is now 
known to be a very important one in certain diseases. 
Various blood-sucking insects may harbor microorganisms, 
and by their bite introduce these germs into the body. 
Examples of such infections are malaria and yellow fever, 
carried by the mosquito, bubonic plague by the flea and 
sleeping sickness by the tse-tse fly. Organisms tend to 
become more virulent after passage through a susceptible 
animal. The resistance to infection varies in different 
individuals and is affected by many circumstances. It is 
well known that some people are susceptible to infections and 
also that conditions which depress vitality predispose to 
infection. Such factors are exposure, malnutrition, excessive 
fatigue, debilitating disease, age, confinement, unhygienic sur- 
roundings and bodily excesses. Local conditions which 
favor infection in wounds are the presence of foreign material, 
pockets or so-called dead spaces into which blood or serum 
may accumulate, lacerations and devitalization of tissues 
by injury or chemical action, and interference with the blood 



384 ASEPSIS AND ANTISEPSIS 

supply by constriction, tight sutures, direct damage to blood- 
vessels, etc. 

Immunity. — Certain organisms are pathogenic to man but 
not to lower animals and vice versa. Some affect only certain 
species. When man or animal is entirely insusceptible to 
infection with a certain organism he is said to possess a 
natural immunity. An acquired immunity may be produced 
by a previous attack of the disease, by vaccination, or by the 
introduction into the body of a serum which has a neutraliz- 
ing or antagonistic action against the infection or its toxins. 
Active immunity is the result of measures which heighten the 
resistance of the individual against infection. The best 
examples of this are vaccination against smallpox and typhoid 
fever. Passive immunity is that which is conferred by the 
injection into an animal of the serum obtained from another 
animal which has been previously immunized. Active im- 
munity usually lasts for a considerable length of time, while 
passive immunity is only temporary. The substances in the 
body fluids which confer immunity are of two main varieties. 
Those which attack the bacteria directly causing their death 
and disintegration are known as bactericidal substances. 
Some infections, especially those which produce the soluble 
exotoxins, cause the body to form substances which combine 
with and neutralize these toxins, thereby gaining the name 
antitoxins. 

Antitoxins. — The production and use of antitoxins depends 
upon the above principles. The best known example is in 
diphtheria. A horse may be so immunized against diphtheria 
toxin by successive injections of ascending doses of toxin that 
the animal's serum becomes able to neutralize an enormous 
amount of this poison. By introducing this antitoxic serum 
into a susceptible person, a passive immunity is conferred 
which temporarily protects against the disease, or after the 
disease is established it will neutralize the toxemia and assist 
in recovery. 

Tetanus, hydrophobia, anthrax and infections with the 
pneumococcus, meningococcus, streptococcus and staphylo- 
coccus are often treated on these principles. 



SURGICAL BACTERIOLOGY 385 

Phagocytosis and Opsonic Treatment. — Certain cells of the 
body have the power of engulfing bacteria and causing their 
destruction. Cells which possess this property in the highest 
degree are the polymorphonuclear leukocytes of the blood 
and certain endothelial cells which line the vascular channels 
and serous cavities. These cells are known as phagocytes. 
Certain substances may be present in the blood which by their 
previous action upon the bacteria greatly assist the phago- 
cytes in this process of devouring the invading bacteria. 
Their action is to render the organisms more susceptible to 
phagocytosis and for this reason they are called opsonins, 
after a Greek word meaning to prepare a meal. The forma- 
tion of opsonins may be stimulated by the injection of killed 
bacteria into the body. 

Bacterial Vaccines. — Bacteria after artificial cultivation 
may be suspended in salt solution, and either killed by heat or 
so devitalized by other means that their power of multiplica- 
tion is abolished. They are then no longer able to produce 
disease and may be introduced in proper amounts into the 
body by means of hypodermic or intravenous injection. 
Bacterial vaccines or bacterins are such suspensions standard- 
ized to contain a known number of bacteria per cubic centi- 
meter. By beginning with small doses and increasing at 
intervals, the active immunity of the body against a certain 
organism or organisms may be considerably increased. This 
immunity is highly specific and does not, as a rule, confer 
additional resistance against other organisms or even against 
other strains of the same organism. It is best, therefore, to 
use the organism isolated from the disease when it is desired 
to employ this treatment. Such a vaccine is said to be 
autogenous. When this is impracticable or impossible vac- 
cine may be made from an organism which is identical so far 
as can be determined. This is a stock vaccine. At times 
mixtures of bacterial suspension are employed which are 
known as mixed vaccines. Not all infections are amenable 
to this kind of treatment. The best results have been 
obtained in chronic pyogenic infections, such as acne and 
furunculosis. It is valuable also in chronic infective condi- 
tions of the pulmonary and urinary tracts. The results are 
less satisfactory in acute infections. 
25 



386 ASEPSIS AND ANTISEPSIS 

Leukocytosis. — This consists in a marked increase in the 
number of the polynuclear leukocytes over the normal, about 
8000, in the circulating blood which is frequently observed in 
local inflammatory processes, in most acute infectious diseases 
and in some toxic conditions. A slight rise in the leukocyte 
count may be observed during the height of digestion, but 
this is usually trivial. The leukocytosis of inflammation is 
caused by chemotaxis which is an attraction exerted by the 
products of bacterial activity upon the blood-making organs 
which are probably stimulated to an increased rate of produc- 
tion. Leukocytosis is generally much more marked if pus 
exists than if the exudation is serous or fibrinous. 

The number of leukocytes per cubic millimeter of blood 
may be increased in inflammation from 8000, the normal, to 
15,000 or 50,000, the amount not necessarily indicating the 
severity or extent of the focus of inflammation. It is found 
in suppurative and gangrenous inflammations, in acute articu- 
lar rheumatism, scarlet fever and pneumonia, and is fre- 
quently observed after copious hemorrhage. Cases of rapidly 
growing sarcoma often show this condition. It is absent in 
typhoid fever, tuberculosis, malaria and influenza. 

The degree of leukocytosis may be considered a general 
index to the intensity of the infection and to the strength of 
the patient's resisting powers in reacting against it. Intense 
infections in individuals, whose resisting powers are great, 
produce marked leukocytosis, while the presence of an infec- 
tion of similar intensity in one whose resisting powers are 
weak fails to cause decided leukocytosis. 

If a sudden overwhelming septicemia accompanies the 
beginning, of an inflammation, as in peritonitis, caused by 
intestinal perforation, leukocytosis may fail to develop, and 
may be absent when an abscess exists, which is well encapsu- 
lated. 

From these facts it is evident that leukocytosis is a symp- 
tom which may be very useful in diagnosis, but it must be 
interpreted with care. 

The determination of the percentage of polymorphonuclear 
leukocytes by a differential count possesses some value in 
surgical infections, as it has been shown that very severe 



SURGICAL BACTERIOLOGY 387 

infections may show an abnormally large percentage'of these 
cells even when leukocytosis is slight or absent. Normally, 
the polymorphonuclear cells form about 70 per cent of the 
leukocytes in the circulating blood. In severe infection they 
may be as high as 90 to 98 per cent. 

The same man should make all of the counts on one 
patient as the individual equation is very important in this 
procedure. 

Varieties of Bacteria. — Bacteria of Suppuration. — Pyogenic 
Bacteria.— A. large number of bacteria are capable of giving 
rise to suppurative inflammation, but the most important are 
the staphylococcus, especially the Staphylococcus pyogenes 
aureus, and the Streptococcus pyogenes or Streptococcus 
erysipelatis, they being identical. Besides these, as rarer 
causes, we have the Bacillus pyocyaneus, the Bacillus coli 
communis, the typhoid bacillus, the gonococcus, the Diplo- 
coccus pneumoniae and the Bacillus pneumoniae (Fried- 
lander) . 

Staphylococcus Aureus. — This is so named because of the 
golden pigment which it produces in artificial culture. It is 
the common cause of boils, carbuncles and usually of acute 
osteomyelitis. It may gain entrance into the circulation, 
giving rise to bacteriemia, and being transported to various 
parts of the body may there set up abscesses or other inflam- 
matory conditions. It is widely distributed, often being 
found on the normal skin and mucous membranes. It is 
not an uncommon cause of wound infection. (Fig. 254). 

Apparently closely related to this organism, but of lower 
pathogenicity are the Staphylococcus albus and the Staphylo- 
coccus citreus. The first is always found on the skin where 
it seems to be a normal and usually an innocuous inhabitant. 
Occasionally it is the cause of stitch abscesses or other sup- 
purative processes in the skin, and rarely its virulence is quite 
as great as that of the aureus. It is called the albus or white 
coccus because its colonies are white on artificial media. The 
second, the lemon colored coccus, is less common than the 
preceding varieties and its pathogenicity is usually low, but 
like the others, on occasions it is virulent enough to cause 
severe infection and even death. These cocci grow in 



388 ASEPSIS AND ANTISEPSIS 

masses, are readily cultivated and thrive best in air, but are 
able to grow in the absence of oxygen. 

Streptococcus Pyogenes. — This is one of the most important 
of pathogenic organisms. It is found widely distributed 
throughout the animal kingdom (Fig. 255). Certain varie- 
ties are devoid of pathogenic properties while others are so 
deadly as to be almost uniformly fatal when infection occurs. 
It may affect practically any tissue of the body. It shows a 
special tendency to spread by means of the blood and lymph 
streams. It is the usual cause of so-called blood poisoning, 
and it causes the most dangerous variety of puerperal fever. 
It may itself produce or act as a serious complicating infection 
in such conditions as pneumonia, empyema, scarlet fever and 

Fig. 254. Fig. 255. 

f '>* /VO 

Staphylococcus pyogenes aureus. Streptococcus pyogenes. 

smallpox. A large proportion of deaths in the great epi- 
demics of the World War were due to this organism as well 
as many which resulted from wounds complicated by strep- 
tococcus infection. Erysipelas is one of its manifestations. 
It is not a spore-producing germ, and is readily killed by 
heat or exposure to antiseptics for a sufficient length of time, 
but its ubiquity makes scrupulous technic necessary to avoid 
contamination. 

Diplococcus Pneumonia. — This organism commonly called 
the pneumococcus is the most common cause of pneumonia. 
It is frequently found in the human mouth and throat. The 
most common surgical complication of pneumonia is empy- 
ema which is a collection of pus within the pleural cavity; 
abscesses of the lung itself may occur. This organism is 



SURGICAL BACTERIOLOGY 



389 



Fig. 256. 



capable also of producing bacteremia and septicemia and 
may attack the joints, the meninges, middle ear and mucous 
membranes. Several varieties of this organism have been 
distinguished, a fact which must be considered in connection 
with treatment by vaccines or serum. It is a small oval 
organism usually growing in pairs or sometimes in short 
chains and possesses a mucoid capsule which aids in its 
differentiation. 

Gonococcus.- — This, the germ of gonorrhea, is a kidney- 
shaped coccus, arranged in pairs, with the concave edges 
toward each other; the diplococci usually inhabit the pus 
cells, but are occasionally free (Fig. 256). Besides specific 
urethritis, it causes salpingitis, oophoritis, arthritis, endo- 
carditis, conjunctivitis, proctitis and other lesions. 

Bacillus Coli Communis. — The colon 
bacillus is an invariable and apparently 
a normal inhabitant of the intestinal 
tract. In appearance and cultural reac- 
tions it closely resembles the bacilli of 
typhoid fever and dysentery and certain 
other members of the intestinal group of 
organisms. It is the most common cause 
of peritonitis, being capable of causing 
suppurative inflammation of the perito- 
neum to which it gains entrance from an injury or disease 
of some intra-abdominal organ, notably the appendix. The 
pus caused by this infection possesses a characteristic foul 
odor. It is a common cause of wound infections, particularly 
after abdominal operation. It is often responsible for cys- 
titis, pyelitis and infections of the kidneys. It is a common 
secondary infection in conditions which may have been due 
in the first place to other microorganisms. It is rod shaped, 
usually short and does not form spores. 

Bacillus Tuberculosis. — This is probably the most import- 
ant single pathogenic microorganism. Its only serious rival 
is the Streptococcus pyogenes and its close relative, the pneu- 
mococcus. It may attack practically any tissue in the body 
but is most common in the lungs, the lymph nodes, the bones , 
and the intestines. In the skin and mucous membranes it 




Gonococcus. 



390 



ASEPSIS AND ANTISEPSIS 



produces ulcerations which are very resistant to treatment. 
The unit lesion in tuberculosis is the tubercle, which is a 
colony of bacilli within the tissues about which certain 
characteristic tissue reactions take place, forming a nodule 
or tubercle (Fig. 257). The center of the tubercle usually 
undergoes necrosis, giving rise to a cheesy or caseous material 
and the process is known as caseation. These tubercles may 
coalesce to form larger foci. Infection of the peritoneum 
results in tuberculous peritonitis; of the pleura, tuberculous 
pleurisy; of the meninges, tuberculous meningitis. Slowly 
progressive glandular enlargements in the neck of the young 
are usually tuberculous, the tubercle bacilli gaining entrance 

through the tonsils or mucous 
FlG - 257 - membranes. Disease of the 

spine, causing the common 
hunchback deformity, is due to 
tuberculosis of the vertebrae. 
Disease of the hip and knee, 
such as "white swelling," are 
often tuberculous. Softening of 
the caseous foci produces thin 
yellowish pus, which often forms 
without pain, heat or other 
signs of inflammation, and is 
Tubercle baciin. therefore known as a "cold 

abscess." The organism does 
not form spores and may readily be killed by heat but is 
resistant to antiseptics, probably on account of a fat-like 
envelope. 

Bacillus Typhosus. — The typhoid bacillus closely resembles 
the colon bacillus. It is the specific cause of typhoid fever. 
Surgical conditions are not infrequently complications or 
sequelae of typhoid fever, such as perforation of the intestine, 
cystitis, inflammations of the kidney, periostitis and chole- 
cystitis. Gallstones frequently result from typhoid infection 
of the gall-bladder. 

Influenza Bacillus. — This is a very minute organism which 
causes true influenza. Influenzal infections are prone to be 
complicated by secondary or associated infections, especially 




SURGICAL BACTERIOLOGY 391 

with the streptococcus and pneumococcus. It is a factor in 
the production of certain chronic pulmonary diseases such as 
bronchiectasis. 

Diphtheria Bacillus. — This is the causative organism in 
diphtheria which occasionally demands surgical interference 
in the form of intubation or tracheotomy, owing to occlusion 
of the larynx and upper trachea by the membrane and the 
inflammatory swelling peculiar to this disease. It is capable 
of growth upon the surface of wounds and mucous mem- 
branes other than those of the throat. Such infections are 
recognized by the serious constitutional symptoms, by the 
necrotic and adherent membrane which forms on the surface 
and by the results of culture made from the suspected tissue 
and incubated for twelve to twenty-four hours. The organ- 
isms have a characteristic morphology 
and staining reaction which may be FlG - 258 - 

recognized microscopically. ^ ^N* 

Tetanus Bacillus. — This is a spore- u jf % ^/ %c 
forming anaerobe which causes the dis- y °"? /^>o 

ease commonly known as lock-jaw. It \f y % / \ i f 
is widely distributed, its principle and -i>f^ o *C- 
natural habitat being in the intestinal \> y> \ 

tract of vertebrates (Fig. 258). It is J "* 

common in fertilized soil, street dirt, Tetanus bacillus. 

surface water, gun wads, wearing ap- 
parel, etc. Methods of sterilizing catgut, which is made 
from the intestines of sheep, must be capable of killing the 
resistant spores which are produced by this organism. A 
considerable number of cases of postoperative tetanus are 
believed to be due to the neglect of such precautions. The 
organism thrives in lacerated, devitalized or punctured 
wounds, danger being much increased by gross contamination 
with soil or dirt. This organism does not invade the general 
circulation, but produces a toxin which is absorbed chiefly 
through the motor nerves. Owing to the firm union which 
takes place between the toxin and the cells of the central 
nervous system when the symptoms begin it is often too late 
to save life by treatment. 



392 ASEPSIS AND ANTISEPSIS 

Bacillus Aerogenes Capsulatus. — The gas bacillus is a strict 
anaerobe and forms spores. It also is widely distributed. It 
is a characteristic invader of war wounds, but is encountered 
occasionally in civil life, especially in lacerated, devitalized 
wounds and those containing foreign material. Together 
with certain closely related organisms it is the responsible 
cause of gas gangrene. It attacks chiefly the muscles, and 
unless interrupted pursues an extremely rapid and fatal 
course. It is characterized by production of gas within the 
tissues which imparts a crackling sensation on palpation. 
Other organisms are usually present, and the pus is sanguin- 
eous and foul. Prostration is early and extreme. Treat- 
ment must be made on discovery and consists of wide exci- 
sion of the infected tissues and in the 
Fig. 259. case f the extremities amputation may 

be indicated. Protective serums have 
been produced, but they are not so 
efficacious as antitetanic serum in the 
prevention and treatment of tetanus. 
It is a large bacillus which takes a 
positive Gram stain and is provided 
with a capsule. These characteristics 
„,, , , -o .„ .. are of assistance in early diagnosis. 

Threads of Bacillus antnra- . ^ mi 

cis containing spores. 1 reponema Pallidum. — The spiro- 

chete of syphilis is shaped like a cork- 
screw, usually showing eight to twelve turns. It is motile 
and does not produce spores. It is an obligate anaerobe 
and produces a great variety of lesions. It may affect 
any tissue in the body and may simulate many surgical 
diseases. The possibility of its presence should never be 
lost sight of, principally to avoid errors in diagnosis and 
treatment. 

Actinomyces. — This is a filamentous organism, standing in 
an intermediate position between the bacteria and the higher 
fungi. It is also known as the ray fungus on account of the 
star-like structure of its growth in tissues (Fig. 260). The 
larger of its colonies are visible as minute yellowish nodules 
resembling sulphur granules, and are characteristic of the 
pus produced by this infection. The microscopical picture is 




SURGICAL BACTERIOLOGY 393 

characteristic. It produces lesions particularly in the lower 
jaw and tongue, characterized by a woody swelling which 
breaks down at various point discharging pus. It most often 
affects cattle, causing the condition known as " lumpy jaw." 
Its normal habitat is believed to be in grain, particularly in 
barley. It may affect man and has been known to occur in 
many different locations. The lesions should not be confused 
with malignant growths. 

Fig. 260. 




Actinomyces. 

The blastomyces or yeasts usually affect the skin or mucous 
membranes. Characteristic examples are blastomycetic der- 
matitis due to a specific yeast and parasitic stomatitis, or 
thrush, due to the Oidium albicans. Occasionally yeasts 
cause general infection. 

The hyphomycetes or moulds are filamentous fungi and are 
a higher form of life than bacteria. Examples of human infec- 
tion with moulds are the various types of ringworm and 
sporotrichosis. 

Putrefactive Bacteria. — Putrefaction is the result of the 
action of living organisms upon organic material, the process 
being due to digestion of the substance by the germs, which 
thus obtain their nutriment. Such organisms may possess 
little or no pathogenic properties, but when they complicate 
infections by other bacteria the end-products of their diges- 



394 ASEPSIS AND ANTISEPSIS 

tive activities may be absorbed and prove toxic to the 
individual. Proteus vulgaris and many anaerobes are espe- 
cially important in the process of putrefaction but a large 
number of bacteria possess the ability to break down organic 
materials. 

Protozoa.— These are minute unicellular organisms repre- 
senting the lowest form of animal life. Malaria, due to the 
Plasmodium malarias and amoebic dysentery, due to the 
Entamoeba histolytica, are the most important. Examples 
of surgical complications of these conditions are chronic 
splenomegaly resistant to antimalarial treatment, and liver 
abscess which is a common complication of ulcerative amoebic 
dysentery. 



THEORY OF ASEPSIS AND ANTISEPSIS IN WOUND 

TREATMENT. 

Before the introduction of Lister's method of treating 
wounds it was the rule in accidental and operative wounds to 
have profuse suppuration, fever, pain and in many cases such 
wound complications as septicemia, pyemia, erysipelas and 
hospital gangrene and the mortality following operative and 
accidental wounds was very high. The mortality in com- 
pound fractures from sepsis was formerly great, but by 
modern methods of wound treatment has been diminished 
to an insignificant percentage. The same diminished mor- 
tality has followed amputations and other wounds, acci- 
dental or operative. 

Lister's method of wound treatment was largely based upon 
the idea that the infection of the wound occurred from contact 
with the air, which contained spores and germs, and his 
method of treatment was chiefly directed to their destruction. 
The air may be a medium of wound infection to a certain 
extent, for it has been demonstrated that dry air contains 
dust in which spores and bacteria are present in much larger 
numbers than in moist air, and such air coming in contact 
with an open wound deposits there numbers of bacteria 
which may set up inflammatory changes. Koch later demon- 



THEORY OF ASEPSIS AND ANTISEPSIS 395 

strated the fact that atmospheric microbes were chiefly of 
an innocuous character, and that wound infection was gen- 
erally caused by bacteria or spores being brought in direct 
contact with the wound by the clothing and skin of the 
patient, the instruments and the hands of the surgeon and 
assistants and unclean surgical dressings. 

Cheyne has shown that the relative number of bacteria 
entering the tissues is an important factor in producing 
suppuration and septic infection, for we know that bacteria 
may exist in an aseptic wound and yet the wound heal and 
remain aseptic, the antiseptic qualities of the blood serum 
and the cell activity in healthy tissues being sufficient to 
destroy or remove a certain number of microorganisms, and 
suppuration or septic infection occurring only when the 
tissues are overwhelmed by the number of organisms or when 
their power of resistance is diminished by injury or disease. 
This explains the satisfactory behavior of wounds which 
pursue an aseptic course where very imperfect details of 
aseptic or antiseptic treatment have been employed. It may, 
therefore, be assumed that infection does not necessarily 
depend upon the presence of a few microbes, but rather upon 
the quantity and quality of the germs which are present 
in the wound. 

Pyogenic microorganisms under different conditions may 
produce a series of different diseases, for it is now generally 
accepted that Fehleisen's Streptococcus erysipelatis is iden- 
tical with Streptococcus pyogenes, which is recognized as 
the cause of very different inflammatory affections. 

Sepsis. — Sepsis is due to the entrance and multiplication 
of microorganisms, or the absorption of their products in the 
body, and is characterized by local inflammation of the 
wound, and marked constitutional symptoms, such as fever, 
disorders of the nervous system and inflammation of the 
viscera. Microbic infection sets up a pathological process 
which causes serious wound complications, and differs materi- 
ally from that process which attends the repair of wounds that 
run an aseptic course. Suppuration in a wound is considered 
clinically to be due to the presence of bacteria, for their exclu- 
sion will prevent its occurrence. 



396 ASEPSIS AND ANTISEPSIS 

Asepsis. — Asepsis aims at thorough sterilization of the 
field of operation and of all objects brought in contact with 
the wound, and the exclusion of microorganisms by occlusive 
sterilized dressings. 

Antisepsis. — Antisepsis, on the other hand, has in view the 
destruction of microorganisms by keeping germicidal agents 
constantly in contact with the wound. The object of anti- 
sepsis is, therefore, to produce asepsis. 

Xo surgeon should undertake the performance of an opera- 
tion or the treatment of an open wound without having 
clearly impressed upon his mind the important part that 
pyogenic and specific microorganisms may play in the subse- 
quent course of the wound. 

Methods of Disinfection or Sterilization. — Since the major- 
ity of wound complications are due to the presence in the 
wound of microorganisms, it is the duty of the surgeon to 
prevent their contact with it, or to employ means for their 
destruction. We must, however, employ means of disin- 
fection or destruction of these microorganisms which will 
not have any injurious effect upon the tissues with which 
they come in contact. Mechanical disinfection or sterilization 
is applicable to wounds only to a moderate extent, but is 
employed to remove any microorganisms which may be pres- 
ent upon the objects which are to come in contact with the 
wound, namely, the hands of the surgeons and assistants, 
instruments and the skin surrounding the wound. Mechani- 
cal disinfection is accomplished by the use of friction with 
a brush, soap and water. Chemical sterilization by means 
of germicidal solutions may be used for disinfection of wounds, 
but are most useful in the disinfection of the hands of the 
operator, the skin of the patient, the instruments and the 
dressings. If these have been carefully employed before the 
wound is made, their subsequent use in the wound is usually 
unnecessary. The recently adopted method of debridement 
of wounds followed by Carrel-Dakin treatment represents 
both their mechanical and chemical sterilization. 

Some forms of bacilli contain spores which resist the action 
of germicidal substances, while the bacilli themselves are 
readily destroyed by these agents; the surgeon should, there- 



METHODS OF DISINFECTION OR STERILIZATION 397 

fore, employ that means of disinfection which is generally 
applicable to the destruction of both bacilli and their spores. 
The bacilli of anthrax and tetanus contain spores; hence to 
destroy these organisms is a matter of more difficulty than to 
render harmless such microorganisms as Staphylococcus pyo- 
genes aureus, albus and citreus, Streptococcus pyogenes and 
Streptococcus erysipelatis and the bacilli of diphtheria and 
glanders, which contain no spores. 

Heat when used as a germicide cannot be applied to the 
wound itself, except in cases where a limited surface of the 
wound may be touched with the hot iron. Heat can, there- 
fore, be used only for the disinfection of substances coming in 
contact with the wound, and for this purpose it is employed 
in the form of steam, dry heat or boiling water. 

Wounds may be treated by using either the aseptic method 
or the antiseptic method, and at the present time these two 
methods are to a certain extent combined — that is, it is 
impossible to be strictly aseptic without employing means 
of disinfection by the use of antiseptics. The aseptic method, 
which employs germicidal substances only for the purpose of 
sterilization of objects coming in contact with the wound 
when their disinfection by heat is impossible, is the method 
which has generally been adopted. 

Antiseptic Method. — In the antiseptic method the steriliza- 
tion of the field of operation, the hands of the surgeon and 
assistants, which for surgical purposes should also include the 
forearms, the instruments, ligatures, sponges and sutures, is 
accomplished by mechanical sterilization as well as the use 
of germicidal solutions, and, in addition, the wound is irri- 
gated frequently during the operation with germicidal solu- 
tions, and is afterward covered with dressings impregnated 
with germicidal substances. The antiseptic method was that 
first employed, and, recognizing its value in surgical pro- 
cedures, some surgeons still continue to employ this method ; 
but it has certain disadvantages. Recent investigations have 
shown that many germicidal substances have not the power 
which was formerly attributed to them, as they only arrest 
bacterial development; many chemical germicides cause the 
formation of a dense layer of coagulated albumin when 



398 ASEPSIS AND ANTISEPSIS 

applied to the tissues, and also fail to destroy microorgan- 
isms associated with fatty or oily substances. Germicides 
may also form chemical combinations with the tissues with 
which they come in contact, seriously impairing their germi- 
cidal action. Antiseptic substances which are active as 
germicides often cause irritation of the surface of the wound, 
interfering with its repair. 

It has been shown that irrigation of a fresh wound with a 
1:10,000 solution of bichloride of mercury is followed by 
distinct evidence of superficial necrosis of the tissues. Anti- 
septic irrigations of wounds is apt to cause very free oozing 
of serums which necessitates the use of drainage, and makes 
frequent dressing of the wound necessary. Many antiseptic 
substances produce marked toxic effects upon the patient, 
and also cause severe irritation of the skin with which they 
come in contact. 

Aseptic Method. — In employing the aseptic method in the 
treatment of wounds, the field of operation, the hands of the 
surgeons and assistants, the instruments, ligatures, sponges 
and suture are sterilized mechanically with soap and water 
and by the use of germicidal solutions and heat, and after 
this has been accomplished, relying upon the completeness of 
the sterilization, no germicidal substances are brought in 
contact with the wound, sterilized water or sterilized salt solu- 
tion being used if it is necessary to flush the wound, and the 
dressings employed are those only which have been sterilized 
by moist or dry heat. The advantages of the aseptic method 
are as follows: The method is applicable to all parts of the 
body; wounds treated by this method heal more promptly 
and do not require frequent dressing; there is no risk of toxic 
effects and there is no irritation of the skin by the dressings. 
Dry sterilized dressings are efficient to produce absorption, 
and at the same time the dryness may be a factor in the 
destruction of germs, for depriving bacteria of moisture robs 
them of one of the conditions necessary to their existence. 
The aseptic method is, therefore, to be preferred to the anti- 
septic method in the treatment of wounds wherever it is 
possible. 

The aseptic method has steadily increased in popularity 



AGENTS EMPLOYED TO SECURE ASEPSIS 



399 



and has largely supplanted the antiseptic method in surgical 
practice. 

Agents Employed to Secure Asepsis. — A great variety of 
agents possessing more or less germicidal properties have 
been at different times employed in the practice of aseptic 
or antiseptic surgery; those most employed at the present 
time are heat, bichloride of mercury, carbolic acid, iodoform, 
formalin, iodine, picric acid, formaldehyde, chloride of zinc, 
acetate of aluminum, peroxide of hydrogen, creolin, perman- 
ganate of potassium, sulphocarbolate of zinc, salicylic and 
boric acids, acetanilid, aristol, nitrate of silver, argyrol, pro- 
targol, Carrel-Dakin solution, chlorazene, hychlorite and 
dichloramine-T, flavine, B. I. 
P. P., and mercurochrome. Fj g- 261. 

Heat. — The most reliable and 
universally available agent for 
the destruction of microorgan- 
isms is heat, either dry or moist; 
many forms of bacteria are ren- 
dered inert at a temperature of 
140° F., and none can withstand 
the application of moist heat at 
212° F. Spores which will re- 
sist the action of powerful germi- 
cides for a considerable time are 
destroyed by boiling for a few steam sterilizer. 

minutes. Dry heat is not as 

efficient for sterilization as moist heat, for some spores will 
resist dry heat of 284° F. for three hours. As moist heat is 
the most efficient sterilizer it should be preferred and can 
always be made use of for this purpose by boiling the instru- 
ments and dressings for a few minutes; and if for any reason it 
is thought advisable to employ dry heat as a sterilizer, this 
may be made use of by baking the instruments or dressings in 
a hot oven. The best results may be obtained by the use of 
moist sterilizers (Fig. 261). By the use of these, surgical 
supplies can be subjected to the action of steam under pres- 
sure, thus increasing its penetration and sterilizing effect. 
An improvised sterilizer may be made by placing a per- 




400 ASEPSIS AND ANTISEPSIS 

forated metal stand inside a large kettle, so that only the 
steam comes in contact with the instruments and dressings. 

Bichloride of Mercury. — This is employed as an antiseptic in 
watery solutions varying in strength from 1 : 1000 to 1 : 10,000. 

The solution of 1 : 1000 to 1 : 1500 is used only for the irriga- 
tion and disinfection of the hands and skin; for the irrigation 
of wounds, a solution of 1 : 2000 or 1 : 4000 may be employed. 
At the present time bichloride solutions are not frequently 
used in fresh wounds on account of their irritating effects. 
Where continuous irrigation is kept up, or where it is em- 
ployed in large cavities, a still weaker solution, 1:5000 to 
1 : 10,000, should be employed. 

In using bichloride solutions the surgeon should watch the 
patient carefully for signs of poisoning due to absorption of 
bichloride of mercury; the symptoms denoting this are 
vomiting, fetid breath, salivation, inflammation of the gums, 
diarrhea, blood-stained stools and bleeding from the mouth 
and nose. Locally the use of moist bichloride dressings may 
cause well-marked dermatitis. The continuous application 
of bichloride solution to the hands of the surgeon causes the 
skin to become roughened and blackens the nails. 

In preparing solutions of bichloride of mercury for use, it 
will be found convenient to have a concentrated solution of 
the salt in alcohol, 1 part of the bichloride to 10 parts of 
alcohol; this can be kept in a well-stoppered bottle, and to it 
should be added one teaspoonful of common salt, which 
prevents disintegration of the mercuric compound. One tea- 
spoonful of this solution added to 1 quart of water makes a 
1:2500 solution. 

A 10 per cent bichloride solution may be made as follows: 

Bichloride of mercury 2 parts. 

Sodium chloride 1 part. 

Dilute acetic acid 1 " 

Aquae dest 16 parts. 

Or the solution may be prepared with tartaric acid in the 
proportion of 5 parts of the acid to 1 part of bichloride of 
mercury, the following formula being employed: 

Hydrarg. chlor. corrosiv grs. xv. 

Ac. tartaric grs. lxxv. 

Aquae dest Oij. 



AGENTS EMPLOYED TO SECURE SEPSIS 401 

Pellets containing a definite amount of bichloride of mer- 
cury compounded with a few grains of common salt or muriate 
of ammonium, which, when dissolved in a definite quantity of 
water, make a solution of 1 : 1000 or 1 : 2000, will also be found 
very convenient for the preparation of solutions. The pellets 
should also contain a little coloring matter, which gives a 
faint color to the solution and serves to distinguish it from 
other solutions. Bichloride solutions cannot be used to 
sterilize instruments on account of their corrosive action on 
ferrous metals. 

Biniodide of Mercury. — This drug possesses germicidal prop- 
erties equal to or greater than the bichloride of mercury; it is 
used in the same strengths as the latter; it is less irritative, 
does not form a mercuric albuminate and does not tarnish 
metal instruments. 

Carbolic Acid. — This drug is employed in solutions of 1 : 20 
or 1 : 40. The stronger solution, 1 : 20, is usually employed 
to sterilize instruments, the latter being allowed to remain in 
this solution for thirty minutes before being used. As a 
carbolic solution of this strength benumbs and cracks the 
skin of the hands of the operator, it should be diluted just 
before the instruments are required, by adding an equal quan- 
tity of boiled water, making it a 1 :40 solution. The rusting 
of steel instruments and the dulling of the edges of knives by 
exposure to carbolic acid may be prevented by the addition 
of 5 per cent of sodium carbonate to the solution. 

The 1 : 40 or 1 : 60 solution is used for the irrigation of 
wounds and the washing of sponges. As carbolic acid in 
strong solutions is a local caustic and coagulates albumin, it 
should not be used in fresh wounds. A ready method of 
making a 5 per cent carbolic solution is to add one table- 
spoonful of carbolic acid to one pint of hot water. 

In using carbolic acid solutions continuously, the surgeon 
should be on the watch for symptoms of poisoning, which 
will be manifested by dark-colored urine, headache, dizziness, 
vomiting and in severe cases bloody diarrhea, hemoglobin- 
uria and death from collapse. Carbolic acid solutions should 
be used with great caution in young children, as they seem to 
be more susceptible than adults to its constitutional effects. 
2<3 



402 ASEPSIS AND ANTISEPSIS 

The use of weak solutions of carbolic acid seems to involve 
more risk of toxic action than does the employment of the 
pure drug, the superficial layer of tissue being coagulated by 
the latter, so that absorption of the drug is prevented. 
Gangrene of the skin and subjacent tissues has frequently been 
observed to follow long-continued use of quite dilute solutions 
of carbolic acid or of ointments containing small quantities of 
the drug. Cases of gangrene of the fingers and toes from this 
cause are not infrequently seen. 

Iodoform. — Iodoform has been shown by experimental 
research to possess little direct germicidal action, but in spite 
of this fact clinical experience has proved that it possesses 
powerful antiseptic properties, due, as shown by Behring and 
De Ruyter, not to the destruction of germs, but to its under- 
going decomposition in their presence, thus inhibiting their 
activity. It may be rendered absolutely sterile by exposing 
it to heat, and, as it is easily decomposed, fractional steriliza- 
tion may be employed, or by washing it in a 1 : 1000 bichloride 
solution; it should then be dried and kept for use in closely 
stoppered bottles. Iodoform is often employed in the form 
of a powder as an application to wounds, and is frequently 
used in aseptic wounds which are liable from their position to 
become infected, such as those about the mouth, rectum and 
vagina, and is especially useful as a dressing in infected 
wounds and in tubercular or syphilitic ulcers and in bone 
cavities. In operations upon the mouth, anus, rectum, 
uterus and abdominal cavity iodoform gauze packing is 
largely employed, and serves to keep the discharges from 
becoming foul, thus often preventing septic intoxication; it 
must, however, be used with caution in the mouth. Iodo- 
form collodion, made by adding iodoform (gr. xlviij) to col- 
lodion (f5j) is a useful dressing in superficial wounds. Iodo- 
form may also be employed in the form of an ethereal solution, 
iodoform (gr. xv) and ether (fg j), as an application to wounds 
or ulcers. An emulsion of iodoform in iodoform (5j) and 
sterilized glycerin (5x), or an emulsion of iodoform made 
by adding sterilized iodoform (5j) to boiled olive oil 
(5x) is much employed as an injection in the treatment of 
tubercular abscesses and joints. For packing cavities a 5 



AGENTS EMPLOYED TO SECURE SEPSIS 403 

per cent gauze is best; a 10 per cent gauze is too strong 
except in small amounts. For large cavities a Mikulicz pack, 
consisting of a bag of iodoform gauze stuffed with sterilized 
gauze, may be employed. 

Numerous cases have been reported in which toxic symp- 
toms have followed the use of iodoform, such as urticarial 
eruptions, dermatitis, headache, depression, delirium, mania, 
debility and sleeplessness. Elderly persons and infants are 
very susceptible to the toxic action of iodoform. 

Iodine.— This drug possesses marked germicidal properties. 
It may be used in a solution of 0.5 to 1 per cent for irrigation 
and 0.25 to 1 per cent for dressings. It is extensively used 
for the sterilization of catgut ligatures and in the form of an 
alcoholic solution it is frequently employed to sterilize the 
skin before operations. The skin should be perfectly dry 
when the iodine is applied. 

Picric Acid. — This drug may be used in 1 per cent aqueous 
solution; gauze saturated with this solution is used in the 
treatment of burns. A 2 per cent alcoholic solution is 
employed for the sterilization of the skin. 

Formaldehyde. — This is a pungent, penetrating gas, possess- 
ing valuable antiseptic properties, which is principally used 
for the disinfection of clothing, instruments, bedding and 
rooms. Acids may be generated by boiling commercial 
formalin or by pouring formalin over crystals of potassium 
permanganate in the proportion of 16 ounces of formalin to 
6f ounces of permanganate. 

Formalin. — This is a 40 per cent solution of formaldehyde 
gas in water, and has valuable antiseptic properties. A solu- 
tion of this strength is a powerful irritant, and should not be 
used in the treatment of wounds. It may be used in a 2 
per cent solution to disinfect wounds or instruments, or in 
0.25 per cent solution for irrigation. Brewer recommends 
a 1 per cent solution applied for three minutes to disinfect 
the skin, a 2 per cent solution applied under anesthesia to 
sterilize infected tissue and 0.3 per cent solution for gauze. 

Dakin's Solution. — This is a solution of sodium hyper- 
chlorite, free from caustic alkali and varying in strength of 
0.45 and 0.5 per cent. It was found by Dakin to fulfill the 



404 ASEPSIS AND ANTISEPSIS 

requirements of an ideal antiseptic. In contact with wound 
exudate the solution gives off nascent chlorine which forms 
highly germicidal chloramine. If the solution is of less 
strength than 0.45 or 0.5 of 1 per cent it is too weak to be 
efficient. If used in a strength of more than 0.5 of 1 per 
cent it will be too strong and will irritate the wound and 
adjacent skin. In using this solution of the normal strength, 
the skin surrounding the wound is protected by covering it 
with strips of gauze, saturated with sterilized yellow vaseline. 
It has been demonstrated that the hypochlorites are deter- 
gent rather than bactericidal, especially acting upon dead 
tissues. For this reason sutures and ligatures of silk, linen 
or catgut may be dissolved and secondary hemorrhage result. 
Chromicized catgut is less likely to be dissolved. It is a very 
unstable solution and should not be heated or exposed to 
light and should be prepared fresh daily, and should be kept 
in dark-colored glass bottles. In large quantities it is pre- 
pared by passing chlorine gas through a solution of sodium 
bicarbonate. Daufresne's modification of the original solu- 
tion is more stable and if kept from exposure to light in a 
cool place may retain its active qualities for several weeks. 
It is wiser, however, to use only a freshly prepared solution. 
It is prepared by placing 200 gm. of chlorinated lime (bleach- 
ing powder) which has been proved by test to contain 25 
per cent active chlorine in a 12-liter flask and adding 5 liters 
of water. This mixture should be shaken vigorously for some 
time and allowed to stand for six hours. In another flask 
100 gm. of dry sodium carbonate and 80 to 90 gm. of sodium 
bicarbonate is added to 5 liters of water, and added to the 
chlorinated lime solution. This mixture is actively shaken 
for a few minutes and then the calcium carbonate is allowed 
to settle. In half an hour the supernatant liquid is siphoned 
off and passed through double filter paper. The solution 
should be neutral; if it contains free alkali it should not be 
used. The alkalinity may be corrected by passing C0 2 
through the solution. The technical details of its employ- 
ment in the treatment of wounds, elaborated by Carrel and 
Dakin are given on page 317. 



AGENTS EMPLOYED TO SECURE SEPSIS 405 

Dichloramine-T or Dakin's Oil. — When hypochlorites react 
with proteins free chlorine is changed into non-irritating 
germicidal substances known as chloramines. Chloramines 
can be prepared synthetically and are known as chloragene. It 
can be used in an aqueous 2 per cent solution in much greater 
strength than Dakin's fluid without irritating the wound or 
skin, but in contact with wound exudate the chloramine 
disappears rapidly and must be renewed frequently. It has 
been found that if dichloramine-T is dissolved in chlorinated 
oil the strength of the solution is from 5 to 10 per cent and 
that when applied to a wound the germicide will be liberated 
over a period of eighteen to twenty-four hours. The follow- 
ing formula is often employed : Dichloramine-T powder 
(grs. 156), chlorinated paraffine oil (chlorinated eucalyptol 
§ iij) . This makes a 7.5 per cent solution. 

Dakin's oil is more stable than the Carrel-Dakin solution, 
does not irritate the skin and retains its potency for twenty- 
four hours, thus avoiding frequent dressing, and does not 
require the complicated technic of the former. It is used in 
solutions in strength from 1 to 5 per cent in the treatment 
of wounds, abscesses and burns; in the latter much weaker 
solutions are employed. It may be sprayed or dropped on 
the surface of a wound, or introduced into deep wounds by 
wicks of gauze saturated with the oil to bring it in contact 
with all parts of the wound area. After its application the 
wound should be covered with a light gauze dressing held in 
place by a bandage. Its use should follow thorough debride- 
ment and drainage of infected wounds. 

Chlorcosane. — This is a recently introduced solvent for 
dichloramine-T. It is prepared by melting hard paraffine 
wax with a melting-point of 50° C. and passing chlorine gas 
at a temperature of 120° to 140° C. through it. The melted 
wax absorbs from 45 to 55 per cent of chlorine, the resulting 
straw-colored liquid will absorb 8 per cent of dichloramine-T. 
It is used in a 5 per cent solution and is applied to wounds by 
means of a spray, syringe or cotton swab. 

Flavine. — This is a chlorine compound also known as acri- 
flavine, prepared from coal tar and is an antiseptic which 
possesses the property of destroying bacteria without injur- 



406 ASEPSIS AND ANTISEPSIS 

ing the tissue cells. It is highly efficient as an antiseptic in 
a watery solution of 1 : 1000. It may be used pure or in a 
1 : 100 solution for irrigation. 

Mercurochrome-200. — This is a red powder insoluble in 
water, but readily soluble in sodium hydroxide. It has 
marked antiseptic properties and is used in solutions of 1 : 1000 

B. I. P. P. — This is known as Morison's paste and consists 
of: Iodoform (2 ounces), bismuth subnitrate (1 ounce), 
paraffine and petrolatum to make a thick creamy mixture. 
This paste is decidedly antiseptic and is employed in the 
treatment of wounds and in bone cavities. 

Dakin's Solution. — See p. 317. 

Chlorazene. — This antiseptic was studied by Dakin and 
occurs in a white crystalline powder freely soluble in water, 
in which it makes a faintly alkaline solution. It has the 
same germicidal power as sodium hypochlorite but is much 
less irritating. It is usually employed in a 1 : 1500 solution. 

Hychlorite.— This is a solution of chlorinated soda; each 
100 cc is said to contain 4.05 gm. of sodium hypochlorite, 
3.2 gm. of sodium chloride, 0.25 gm. of calcium hydroxide 
and 0.92 gm. of inert salts. It contains more chlorine than 
the solution of chlorinated soda of the U. S. P. One volume 
of hychlorite diluted with 7 volumes of water is isotonic. 

Both of these preparations are more stable than Dakin's 
solution and may be substituted for the latter when it is not 
possible to get freshly prepared Dakin's solution. 

Silver Nitrate. — This drug has marked antiseptic action 
and is frequently used in solutions of varying strengths in 
the treatment of infected mucous membranes. In the form 
of the solid stick, lunar caustic, it is a most satisfactory 
application to wounds to destroy exuberant granulations. 
A solution of nitrate of silver, 1 : 16,000 to 1 : 24,000, is one 
of the most satisfactory solutions for irrigation of an infected 
bladder. 

Argyrol. — This is an organic silver salt which is less irrita- 
ting than nitrate of silver, but not as efficient as an antiseptic. 
It is used in a 10 to 15 per cent solution as an application to 
mucous membranes. It stains the tissues and clothing and 
the stains may be removed from the latter by soaking in a 
1 : 500 bichloride of mercury solution. 



AGENTS EMPLOYED TO SECURE SEPSIS 407 

Protargol. — This is a silver salt containing 8.3 per cent of 
silver which occurs in a yellowish powder, soluble in hot or 
cold water It is used in a 1 to 5 per cent solution. It is also 
employed in inflammation of the mucous membranes. 

Acetanilide. — This preparation possesses antiseptic prop- 
erties and is frequently used as a substitute for iodoform. It 
may be used in the form of powder as an application to suppu- 
rating or ulcerating tissues, but in tubercular conditions is 
not as satisfactory as iodoform. 

Chloride of Zinc. — Chloride of zinc in a solution of 30 to 40 
grains to water (f§j), is a very powerful antiseptic. When 
employed upon raw surfaces it produces marked blanching 
of the tissues; it is especially useful in wounds which are 
infected or which have been exposed to infection. I have 
found it by all means the best application for the poisoned 
wounds which are received in dissecting dead bodies and in 
operating. In such cases the whole cavity or surface of the 
wound should be swabbed with a 30-grain solution, and then 
the wound should be dressed with moist sterilized gauze. 

Acetate of Aluminum. — This drug is used in solution, and 
is prepared as follows: aluminis, 3vj (24 gm.); plumbi 
acetatis, 5ixss (38 gm.); aquae, Oij (1000 gm.). Mix, and 
filter after standing twenty-four hours. It has decided ger- 
micidal qualities, is employed for irrigation and moist dressing 
where carbolic or bichloride solutions cannot be used, and is 
by all means the safest and best antiseptic substance for wet 
dressings. 

Peroxide of Hydrogen. — Peroxide of hydrogen is employed 
in what is known as the 15- volume solution. It may be 
used in this strength or may be diluted. It is an excellent 
agent for cleaning purulent areas, but has no distinct germi- 
cidal action. It is frequently employed in the sterilization 
of sinuses or suppurating cavities, such as remain after the 
opening of abscesses or result from diseases of or operations 
upon the bones. It is injected into the sinuses and cavities 
by means of a glass syringe, or may be applied to open wounds 
in the form of a spray. Its action is shown by the escape of 
gas and purulent material and it should be used as long as these 
continue to escape. It must be used with caution in sinuses 



408 ASEPSIS AND ANTISEPSIS 

and deep cavities as the sudden generation of gas may pro- 
duce pressure and force -its way into adjacent tissues, thus 
spreading infection. 

Creolin. — This substance is obtained from English coal by 
dry distillation, and has been found to possess powerful germi- 
cidal properties; it is non-irritating and practically non-toxic. 
It is insoluble in water, but forms an emulsion with it which 
possesses marked antiseptic properties. It is especially use- 
ful as a deodorant in offensive malignant ulcers. It may be 
employed for the same purposes as carbolic acid. It is used 
in an emulsion, in strength of from 2 to 5 per cent, and is 
employed in the irrigation of large wounds or cavities of the 
body, and has been most favorably recommended in gyneco- 
logical practice. 

Boric Acid. — This drug has not very marked antiseptic 
qualities and is usually unirritating even in saturated solu- 
tions; but occasionally it produces marked irritation of the 
skin. It is frequently employed in a 5 per cent solution for 
most dressings or fomentations and to cleanse and disinfect 
mucous surfaces and large cavities. It is often employed to 
wash out the bladder before the operation for the removal of 
calculi or growths from that organ. In the dressing of super- 
ficial wounds, or in wounds in which the bichloride or carbolic 
acid dressing produce irritation, an ointment of boric acid, 1 
part, to petrolatum, 5 parts, will be found very satisfactory. 

Boro-salicylic Powder. — This powder, which consists of 4 
parts of boric acid to 1 part of salicylic acid, is used as a 
dusting-powder and as a dressing for wounds. It has been 
recommended highly by Senn in the treatment of fresh 
wounds. 

Salicylic Acid. — Salicylic acid does not have very marked 
antiseptic qualities, but possesses much less toxic action than 
carbolic acid, and is used for somewhat the same purposes. 
Its antiseptic power is said to be increased by the addition of 
boric acid and a boro-salicylic lotion (Thiersch's solution) is 
prepared by adding salicylic acid, 1 part; boric acid, 6 parts; 
to hot water, 500 parts; making a bland solution, which, 
when reduced to 25 to 50 per cent of the original strength, 
may be used for irrigation of the bladder. 



AGENTS EMPLOYED TO SECURE SEPSIS 409 

Permanganate of Potassium.— This drug, owing to its oxidiz- 
ing action, acts as an antiseptic, and is often employed for 
the disinfection of foul wounds and ulcers. It is practically 
non-irritating, and may be used in quite concentrated solu- 
tions, but is usually employed in the following strength: 
Permanganate of potassium, 5j; water, fgj. One fluidraih 
of this solution to 1 pint of water makes a 1 : 1000 solution. 

Aristol. — Aristol, which is a compound of iodine and thy- 
mol, possesses germicidal properties, and has been introduced 
as a substitute for iodoform. It has the advantage over 
iodoform of not being poisonous, and is also without dis- 
agreeable odor. It may be employed for the same purposes 
as iodoform and it seems to be particularly useful as a dressing 
to chronic and specific ulcers. 

Xeroform. — This is a combination of bromine, carbolic acid 
and bismuth. It possesses marked antiseptic properties and 
is frequently used as a drying powder in the treatment of 
wounds or may be combined with petrolatum and used as an 
ointment in the dressing of ulcers. 

Sodium Chloride. — This salt has no direct antiseptic action, 
but is used in the preparation of normal salt or saline solution, 
the strength of which is 0.6 to 0.9 per cent. 

Saline Solution.- — This is prepared by adding 6 drams of 
sterilized sodium chloride to 1 liter of distilled water, which 
is contained in a sterilized oval glass flask. The mouth of 
the flask should be plugged with sterilized cotton and a piece 
of gauze fastened over the mouth and neck of the bottle. 
The solution should be exposed to steam sterilization one-half 
hour on two successive days. Saline solution is non-irrita- 
ting, and is frequently used in the irrigation of fresh wounds, 
to remove foreign bodies or blood clots and for the cleansing 
of mucous and serous surfaces. Its utility by intravenous 
injection or infusion is well recognized (see page 157). In 
emergencies a solution prepared by adding 1 dram of'common 
salt to 1 pint of water which has been sterilized by boiling may 
be employed. 

Sterilization of Water. — Water may be rendered absolutely 
sterile by boiling from fifteen to thirty minutes. It should 
be distilled or filtered before being boiled to remove any inert 



410 ASEPSIS AND ANTISEPSIS 

matter which is not desirable in wounds. After being boiled 
it should be placed in sterilized glass flasks and corked with 
sterilized cotton, the mouths of the flasks also being covered 
with several layers of gauze. It is employed for the irrigation 
of wounds and of mucous and serous surfaces. 

Preparation of Materials used in Aseptic Operations. — 
Dakin's Pads. — See p. 318. 

Gauze Sponges or Pads. — On account of the difficulty in 
satisfactorily sterilizing marine sponges, as well as of their 
expense, folded gauze sponges have largely superseded them. 

Gauze Sponges. — These are prepared by cutting a piece 
of gauze, composed of from twelve to sixteen layers, in pieces 
6 inches square; the four angles of these pieces are then tied 
together or secured by a few stitches. Sponges may also be 
made by folding a piece of gauze 18 inches by 18 inches com- 
posed of two layers so that the cut edges are turned in, the 
resulting sponge being about 4 inches square. 

Gauze Pads. — Gauze pads are made from a piece of gauze 
composed of from sixteen to twenty layers cut the desired 
size, the different layers in each pad being quilted together 
by a few stitches and the edges loosely whipped with a thread 
to prevent them from fraying. Gauze pads are used as a 
substitute for the flat sponges formerly employed in abdom- 
inal surgery, and for the drying of wounds. Where pads are 
used in abdominal operations, to prevent them from being 
lost in the abdomen, it is well to have sewed to each pad a 
piece of tape 12 inches in length, which is allowed to protrude 
from the wound and to which a hemostatic forceps is attached 
Gauze sponges and pads are put in packages, a definite num- 
ber in each package, and marked before being sterilized. The 
pads or sponges may be sterilized by boiling or by exposure 
to steam in a sterilizer, and afterward dried by dry heat. 
They are wrapped in a sterilized covering; if not used within 
twenty-four hours they should be resterilized before being 
used. Warm moist pads should be preferred to dry pads for 
use in the abdominal cavity. 

Silk Sutures and Ligatures. — Silk for sutures or ligatures, 
either the plaited silk or the Chinese twisted silk, should be 
sterilized by boiling from ten to thirty minutes, the time of 



PREPARATION OF ASEPTIC MATERIALS 411 

boiling depending upon the thickness of the threads; frequent 
boiling renders the silk weak. It should then be placed in 
stoppered bottles and covered with a 5 per cent solution of 
carbolic acid or with absolute alcohol, or in 1 : 1000 bichloride 
and alcohol solution. 

As boiling diminishes the strength of the silk, it may be 
rendered sterile by being wound upon a glass spool and placed 
in a test-tube plugged with cotton; the tube should be placed 
under 10 pounds pressure in an autoclave for thirty minutes 
on three successive days. Silk ligatures and sutures are 
extensively used in abdominal surgery for the ligation of 
pedicles and suturing of the viscera. 

Silkworm Gut. — Silkworm gut is an excellent material for 
sutures, and may be sterilized by boiling it for fifteen minutes, 
or by placing it for one-half hour in a 5 per cent carbolic 
solution; after being sterilized it should be kept in 95 per 
cent alcohol. There has recently been introduced an iron- 
dyed black silkworm gut which makes the sutures more 
prominent and thus facilitates their removal. 

Silver Wire Sutures. — Fine silver wire was formerly very 
extensively used as a suture material. The heavier grades of 
silver wire are still used as bone sutures. This material is 
sterilized by boiling. 

Aluminum Bronze . — This material in the form of wire has 
recently been extensively used for bone sutures. It is steril- 
ized by boiling. 

Horsehair Sutures. — This material is frequently used for 
sutures; it is more pliable than silkworm gut and is often 
used for skin sutures. It should be sterilized by boiling for 
fifteen minutes in a 4 per cent solution of carbonate of sodium. 

Equisetene. — This is a fine silk suture material which has 
been recently introduced and is frequently used where horse- 
hair sutures were employed. 

Catgut Ligatures and Sutures. — Catgut is the ideal material 
for ligatures and sutures, but has the disadvantages of diffi- 
culty and uncertainty in its sterilization. Raw catgut is 
often infected with microorganisms and, therefore, thorough 
sterilization alone can render it a safe material for ligatures 
and sutures. It is furnished in threads of different sizes, 00 



412 ASEPSIS AND ANTISEPSIS 

being the smallest, then 0, 1, 2, 3, 4; the greater the diameter 
of the catgut the more difficult is its sterilization. 

Catgut sutures should be secured by a square knot; if the 
catgut is so stiff or wiry that it is difficult to tie it should be 
soaked for a few moments in salt solution, which renders it 
pliable. The ends should not be cut too short, and in apply- 
it to large vessels it is better to secure it by three knots. 

Von Bergmann's Catgut. — This method of preparing catgut 
consists in winding the catgut loosely upon glass rods or 
spools; these spools are placed in ether for twenty-four 
hours; the ether is then poured off and they are placed in 
the following solution: bichloride of mercury, 10 parts; abso- 
lute alcohol, 800 parts; distilled water, 200 parts. Remove 
from this solution after twenty-four hours and place them in 
a similar solution for forty-eight hours; then place in abso- 
lute alcohol. If soft catgut is desired add 20 per cent of 
glycerin to the absolute alcohol. To make the sterilization 
absolutely certain it has been found advantageous to soak 
the catgut for thirty minutes in a 1 : 1000 aqueous bichloride 
solution before placing it in the alcoholic solution of 
bichloride. 

Boiled Catgut. — Catgut may also be sterilized by boiling in 
alcohol under pressure. The most satisfactory method is 
that devised by Fowler, which consists in placing a number of 
strands of catgut in an ordinary test-tube which is filled with 
95 per cent alcohol to within half an inch of the top; a wad 
of cotton is next pushed into the mouth of the tube and a 
cork is introduced. The tubes thus prepared are placed 
inverted in a fruit jar filled with 95 per cent alcohol; the jar 
is then closed and placed in a water bath, and kept at a 
boiling temperature for an hour. Or the catgut may be 
loosely wound upon glass rods and spools and placed in a 
metallic cylinder or jar having an accurately fitting screw top. 
The catgut is then covered with absolute alcohol, the top is 
screwed down and the cylinder or jar is immersed in boiling 
water for an hour. 

Formalin Catgut. — This is prepared by winding catgut 
loosely on glass spools and keeping them for forty-eight hours 
in a vessel containing equal parts of alcohol and ether. They 



PREPARATION OF ASEPTIC MATERIALS 413 

should next be washed for a few minutes in alcohol and 
placed in a jar containing equal parts of alcohol and formalin 
and allowed to remain for several days. The excess of 
formalin should then be washed away with alcohol and the 
catgut kept for use in 95 per cent alcohol. 

Cumol Catgut. — The catgut is rolled loosely on glass spools 
which are placed in a glass beaker having a layer of cotton 
in the bottom; the beaker is covered by a piece of cardboard 
having a hole in the center through which a thermometer is 
introduced and is placed on a sand bath heated by a Bunsen 
burner. Heat is applied until the temperature is raised to 
176° F.; this is maintained for one hour, and removes all 
moisture from the catgut. Cumol, at a temperature of 212° 
F., is next poured into the beaker, completely covering the 
catgut, and the temperature is then raised to 329° F. and 
maintained for one hour. The cumol is next poured off and 
the catgut is allowed to dry in the beaker on the sand bath 
at a temperature of 212° F. for two hours; it is then trans- 
ferred to sterile jars or tubes which should be air-tight. 

Iodine Catgut. — This variety of catgut has recently been 
extensively used with most satisfactory results. The catgut 
is soaked in a 1 per cent solution of iodine for seven days, 
when it is ready for use. The solution is prepared by dissolv- 
ing iodide of potassium, 1 part, and iodine, 1 part, in 100 parts 
of water. The solution is prepared by dissolving the iodide 
of potassium in a small quantity of water, to which the iodine, 
finely powdered, is added and the concentrated solution is 
diluted to a 1 per cent solution. 

The catgut may be kept in the sterilizing solution or in a 
mixture consisting of absolute alcohol, 950 parts, glycerin, 
50 parts, and iodoform finely powdered, 100 parts. 

Chromic Acid or Chromicized Catgut. — Catgut, after being 
soaked in ether for twenty-four hours and washed in alcohol, 
is placed for twenty-four hours in a 4 per cent aqueous 
solution of chromic acid; it is then removed and dried in 
a hot oven, and placed in closely stoppered jars, or may be 
preserved in absolute alcohol. Catgut thus prepared will 
resist the action of living tissues for several weeks, the time 
of its absorption depending upon the size of the gut. Before 



414 ASEPSIS AND ANTISEPSIS 

being used it should be sterilized by either the cumol, alcohol 
or formalin method. 

Owing to the fact that it undergoes very slow solution in 
the tissues, chromicized catgut is often employed for sutures 
or for the ligation of the larger vessels in their continuity, 
and for bone sutures. 

Bartlett's Catgut. — Coils of catgut are strung upon a 
thread for convenience of handling and are dried for four 
hours at temperatures of 160°, 180°, 200° and 220° F. The 
coils are next placed in liquid albolene and allowed to remain 
for several hours. The vessel containing the catgut and albo- 
lene is next placed upon a sand bath and the temperature 
raised to 320° F. which is maintained for two hours. The 
coils are then taken out of the oil with sterile forceps and 
placed in a mixture of iodine crystals, 1 part, and deodorized 
methyl alcohol, 1000 parts. The catgut is ready for use in 
twenty-four hours and may be stored in the same solution. 

Kangaroo Tendon Sutures. — This material is obtained from 
the tendons in the tail of the kangaroo. The dried strands of 
tendon are prepared as is catgut and should be chromicized. 
It is a very strong material and undergoes very slow absorp- 
tion in the tissues, often remaining for sixty days. It is 
used for buried sutures. 

Celluloid Thread. — This is a linen thread introduced by 
Pagenstecher. It is prepared by boiling the thread for thirty 
minutes in a 1 per cent solution of sodium carbonate. It is 
then dried between sterile compresses and soaked for some 
hours in celluloid solution. It may be kept dry or in an 
alcoholic solution of bichloride of mercury. It may be 
resterilized by boiling or under steam pressure. It has 
proved a satisfactory material for sutures and ligatures, and 
may be used in place of catgut or silk. 

Drainage Tubes. — The drainage tubes usually employed 
are prepared from rubber tubing of different sizes perforated 
at short intervals; the black-rubber tubes are softer and 
more pliable than the red-rubber or white-rubber tubes, and 
are generally preferred (Fig. 262) . In using rubber drainage 
tubes in contact with organs on which they may exert injuri- 
ous pressure it is sometimes found of advantage to split the 



PREPARATION OF ASEPTIC MATERIALS 



415 



tube for its entire length which does not alter its shape or 
interfere with its function unless it is subjected to severe 
pressure. Drainage tubes are also made of glass, straight or 
curved (Fig. 263), which are almost exclusively used in 
abdominal surgery, and also of decalcified bone. The tubes 
should be well washed and sterilized by boiling water for a 
few minutes before being used. They may be kept in a 5 
per cent carbolic solution. 



Fig. 262. 



Fig. 263. 





Rubber drainage tube. 



Glass drainage tube. 



Gauze Drainage. — Strips of gauze, either sterilized or iodo- 
form gauze, are often used for drainage, and are preferred 
by some surgeons to the various kinds of drainage tubes. 
This form of drainage is very much employed; it will be 
found that the drainage is more prompt if the gauze is wet 
with saline solution or any antiseptic solution preferred before 
being introduced. Gauze drainage suffers from the disadvan- 
tage of contracting firm adhesions to the surrounding tissues 



416 ASEPSIS AND ANTISEPSIS 

and when its meshes become filled with thick exudate it may 
act as a plug rather than a drain. 

Cigarette Drain. — This consists of a roll of sterilized or 
iodoform gauze covered by rubber protective tissue (Fig. 
264). It may be prepared in lengths of 12 inches and a suffi- 
cient amount cut off as is required by the depth of the wound 
to be drained. It is a very satisfactory form of drain in 
abdominal wounds. 

Fig. 264. 





Cigarette drain. 

Mikulicz Bag or Tampon. — This consists of a roll of gauze 
surrounded by rubber tissue, which is used especially in 
abdominal operations where we desire to obtain pressure to 
arrest hemorrhage and also to secure drainage. 

Catgut and Horsehair Drainage .—Catgut as ordinarily pre- 
pared for ligatures may be used to secure drainage in small 
and superficial wounds; a number of strands are placed in 
the bottom of the wound and the ends are allowed to project 
from one or both extremities of the wound. 

Horsehair or silkworm gut may be employed for the same 
purpose, a number of strands being placed in the wound in 
the same manner. Before being used it should be well 
washed with soap and water and then sterilized by boiling. 

Protective. — Protective is employed to prevent the wound 
from being irritated by the antiseptic substances with which 
the gauze is impregnated or by its irregular surface. The 
great objection to the use of protective is that it sometimes 
interferes with drainage and permits of the accumulation of 
serum beneath it, which may become infected. 

Various materials are employed as protectives; one of the 
best is Lister's oil silk, rubber dam, rubber tissue or silver 
foil, the principal requirement being that they can be readily 
rendered aseptic and do not absorb irritating materials from 
the dressings. 



PREPARATION OF ASEPTIC MATERIALS 417 

Silver Foil. — The inhibitive action of metallic silver on the 
growth of microorganisms is utilized in the employment of 
silver foil to cover the surface of wounds. The foil is steril- 
ized by dry heat and placed directly on the surface of the 
wound after it has been closed by sutures. It is claimed that 
the foil prevents infection of the wound from the exterior and 
also destroys microorganisms which may come in contact 
with it. 

Rubber Dam. — This is a thin, pure rubber tissue, which 
may be cleansed and sterilized with greater facility. It is 
often attached to the drainage tube in abdominal wounds to 
shut off the opening of the tube from the abdominal wound. 
Before being used it should be washed with soap and water, 
rinsed and then placed in a bichloride or carbolic solution for 
a time sufficient to sterilize it. Cut into strips it is a useful 
material for drainage of abscesses and sinuses, especially in 
infections of the ringers and hands. 

Rubber Tissue. — This consists of a very thin sheet of India 
rubber with glazed surfaces which can be obtained from the 
rubber manufacturers; it is employed to cover moist dress- 
ings and, as previously stated, may be used when properly 
sterilized instead of protective for covering the wound. 

Gauze Dressing. — The most convenient and cheapest 
material for wound dressing is a material known to the trade 
as cheesecloth or tobacco-cloth, and for surgical use should 
contain no sizing. From the fact that it has a very open 
mesh, it absorbs well either the materials with which it is 
prepared or the discharges from the wound, and is soft and 
pliable, so that it is a comfortable form of dressing to the 
patient. 

Gauze containing various antiseptic substances was for- 
merly much employed in surgical dressings, but at the present 
time it has been largely superseded by sterilized gauze. 

Bichloride or Corrosive Sublimate Gauze. — Bichloride or cor- 
rosive sublimate gauze is prepared by placing cheesecloth in 
a washing kettle and covering it with water to which is 
added 2 pounds of washing soda or 1 pint of lye; the latter 
is added to dissolve any oily matter which the cheesecloth 
contains, thus making it more absorbent. The gauze is 
27 



418 ASEPSIS AND ANTISEPSIS 

boiled in this solution for an hour, and is then removed and 
washed in boiled water and passed through a sterilized clothes 
wringer; it is then immersed in a 1 : 1000 bichloride solution 
for twenty-four hours; the excess of fluid is then squeezed 
out of it, and it may be packed in air-tight jars and preserved 
as a moist gauze, or may be dried in a warm oven and packed 
in sterilized jars and kept as a dry gauze. Dry bichloride 
gauze, unless freshly prepared, possesses little antiseptic 
properties. 

In using the sublimate gauze on delicate skins a dermatitis 
sometimes results which is known as mercurial eczema; this 
is particularly apt to occur if the gauze is moistened or 
covered with rubber tissue. If this condition develops the 
parts covered by the gauze should be rubbed over with boric 
acid ointment or vaseline before it is reapplied, or a sterilized 
gauze dressing should be substituted. 

Iodoform Gauze. — This may be prepared by soaking steril- 
ized gauze in a mixture containing iodoform, 5 parts, glycerin, 
20 parts, and alcohol, 75 parts. This furnishes the 5 per 
cent iodoform gauze; if 10 per cent gauze is desired the quan- 
tity of iodoform should be doubled. When the gauze is 
thoroughly saturated it should be of a uniform yellow color. 
It should then be thoroughly wrung out with sterilized hands 
to remove the alcohol and packed in sterilized jars with 
tight-fitting covers. 

Iodoform gauze may also be prepared by saturating steril- 
ized gauze with a mixture of ether and iodoform, and then 
allowing the ether to evaporate, the iodoform being dis- 
tributed evenly through the gauze. 

Carbolized Gauze. — In preparing carbolized gauze, cheese- 
cloth which has previously been boiled and dried is soaked 
for a few hours in the following solution: resin, 16 ounces; 
alcohol, 5 pints; castor oil, 24 ounces; carbolic acid, 12 
ounces. The gauze is removed from this solution and passed 
through a sterilized clothes wringer, and is then cut into 
pieces from 4 to 6 yards in length, which are folded and 
packed in air-tight jars for use. 

Improvised Aseptic or Antiseptic Dressings. — Aseptic dress- 
ings in cases of emergency may be improvised, where the 



PREPARATION OF ASEPTIC MATERIALS 419 

ordinary gauze dressings cannot be obtained, by tearing 
muslin or mosquito netting into pieces \ yard square and 
placing them in boiling water for a few minutes; they are 
then removed, the excess of moisture is wrung out and they 
are applied to the wound. 

If it is desirable they may be used as antiseptic dressings 
by soaking them for a few minutes in a 1 : 1000 or 1 : 2000 
bichloride solution, or in a 5 per cent carbolic solution. 
This dressing will keep the wound aseptic until a more 
elaborate dressing can be obtained. 

Sterilized Bandages. — Sterilized bandages are prepared by 
tearing or cutting gauze into strips from 2\ to 3 inches in 
width, and forming these strips into rollers which are steril- 
ized by steam or dry heat. They should be used soon after 
being prepared, or, if kept for any time, should be resterilized 
before being used. 

Sterilized Towels, Operating Suits and Gowns. — These are 
wrapped in muslin covers and sterilized by steam under 
pressure and dried in the same manner as gauze dressings. 

Bichloride Cotton. — This material is prepared by soaking 
absorbent cotton in a 1 : 1000 bichloride solution for twenty- 
four hours and allowing it to dry, or it may be dried in a hot 
oven; when dry it is packed in jars or in air-tight boxes. It 
was formerly much used, but has now been superseded by 
sterilized cotton. 

Sterilized Cotton. — Sterilized cotton is prepared by placing 
absorbent cotton, enclosed in perforated metal cans, in a 
steam sterilizer and allowing it to remain for half an hour 
under ten pounds' pressure. If kept for a short time it should 
be resterilized before being used. 

Moist Sterilized Gauze Dressings. — Moist sterilized gauze 
dressings may be prepared by subjecting gauze which has 
been boiled in soda solution to the action of boiling water or 
of steam for thirty minutes. Gauze thus treated should be 
used as soon as prepared. 

Sterilized Gauze. — This is prepared by cutting pieces of 
gauze the desired size, wrapping them in a towel and placing 
them in wire baskets; or the gauze may be placed in cylindri- 
cal tin boxes, 3 inches in diameter and 8 inches in height, with 



420 



ASEPSIS AND ANTISEPSIS 



perforated metal covers, covering the gauze at each end with 
a layer of cotton before putting on the covers. The gauze is 
next placed in a steam sterilizer and subjected to 10 pounds' 
pressure of live steam for half an hour. The steam is then 
shut off from the sterilizer and allowed to circulate in the 
jacket of the apparatus without pressure for half an hour to 
dry the dressings. If the gauze has been sterilized in metal 
cases it may be kept for some time and still remain sterile. 
Cotton may be sterilized in the same manner. 

Fig. 265. 




Hot-air sterilizer. 



Dry Sterilized Gauze Dressing. — Dry sterilized gauze dress- 
ings are prepared by cutting gauze into proper lengths and 
packing it loosely in wire cages or perforated metal cans, 
which are next placed in a dry sterilizing oven for several 
hours, and upon removal it is placed in air-tight jars or metal 



SEPSIS IN TREATMENT OF WOUNDS 421 

boxes. In using dry sterilized gauze dressings it is safer to 
have the dressings freshly sterilized immediately before each 
operation. A convenient form of sterilizing oven is shown 
in Fig. 265. Towels and operating gowns may be sterilized 
in the same oven. 

Paraffine Gauze. — This is prepared by impregnating white 
coarse-meshed mosquito netting with a mixture of paraffine, 
2 parts, petrolatum, 2 parts, and stearin, 1 part, and 0.5 per 
. cent of carbolic acid may be added. This is a non-adherent 
dressing, which provides good drainage through the meshes 
of the gauze. One or two layers of this gauze are laid over 
the wound and covered by an absorbent gauze dressing. It 
is useful in the dressing of burns and scalds, and is a most 
satisfactory dressing to apply over skin grafts before a gauze 
dressing is applied. 

Resterilization of Used Gauze Dressing. — Formerly all gauze 
dressing which had been used was thrown away. This 
resulted in an enormous waste of material. In most hospi- 
tals the used gauze if not soiled with pus is resterilized and 
is perfectly safe. The gauze is first soaked and washed to 
remove blood or stains, then boiled for thirty minutes in a 
steam laundry machine and dried in a centrifugal drier, 
and next placed in a drier heated to a high temperature by 
pipes carrying superheated steam. The gauze is then steril- 
ized for two or three successive days. By this treatment it 
has been found that gauze, even if soiled with pus, is rendered 
absolutely sterile. 

Methods and Dressings Employed to Secure Asepsis in 
the Treatment of Wounds. — To prevent infection of wounds 
the various chemical sterilizers and dressings are employed 
in different ways and the principal types of dressings are as 
follows : 

The primary sterilization of the wound should be done with 
tincture of iodine or dichloramine-T before the dressings are 
applied. 

Method by Simple Drying. — This method is employed in 
small and not very deep wounds. The edges having been 
brought together by sutures, the surface of the wound is 
dusted with powdered iodoform, the serum and blood forming 



422 ASEPSIS AND ANTISEPSIS 

with this, as it dries, a scab, which protects the wound from 
infection from without, repair taking place promptly under 
this scab. Treves employs this method of dressing in com- 
pound fractures. A few layers of gauze or a thin layer of 
absorbent cotton saturated with iodoform collodion or tr. 
benzoin (3 j) and collodion (3 vij) may be employed instead of 
iodoform. Dry sterilized gauze and cotton dressings may 
also be employed in this method of dressing. 

Method of Drying and Chemical Sterilization. — The object of 
this method of dressing is to provide a means of sterilizing 
the blood or serum which escapes from the wound, and at 
the same time to insure the sterilization of the air coming in 
contact with the discharges from the wound. It is employed 
in large or deep wounds, where there is always more or less 
escape of blood or serum, and is accomplished by applying a 
number of layers of sublimate or iodoform gauze and sub- 
limated cotton over the wound. Evaporation not being 
interfered with, the whole dressing becomes hardened and 
the wound is surrounded by a large antiseptic crust made up 
of the dressing and serum or blood. 

Moist Dressings. — In this method of dressing the wound is 
covered by layers of moist antiseptic gauze which are kept 
moist and evaporation prevented by applying over them some 
impervious material, such as mackintosh or rubber tissue. 
This method of dressing is not at the present time often 
employed. 

Modified Moist Dressing. — In using this method the wound 
itself is covered by a piece of protective or rubber tissue; 
over this is placed the sublimated or iodoform-gauze dressing 
and some layers of sterilized cotton. In this way the wound 
itself is kept in a moist condition favoring particularly the 
organization of blood clots; the external dressings become 
dry as the discharges which have escaped into them evapo- 
rate, forming an antiseptic crust or covering over the wound. 

Preparation for Aseptic Operation. — Preparation of Patient 
for Operation. — Where it is possible the patient should have 
two or three days' rest in bed before a severe operation, and 
at the same time he can be taught to use the bed pan and to 
urinate in the recumbent posture. The condition of the 



PREPARATION FOR ASEPTIC OPERATION 423 

heart, lungs, blood and kidneys should be investigated. If 
the blood examination shows a percentage of hemoglobin 
under 50 with a corresponding reduction in the red corpuscles 
in cases not associated with hemorrhage operation should be 
postponed until there is an improvement in this respect or 
blood transfusion may be done. The urine should be care- 
fully examined for sugar, albumin, casts, acetone and diacetic 
acid; presence of the latter forbid any but an emergency 
operation. The presence of sugar and granular and fatty 
casts should point to the abandonment or postponement of 
operative procedure, except in urgent cases. 

The presence of valvular disease of the heart with fair 
compensation is not a contraindication to operation, while 
evidence of myocardial changes always renders the result of 
serious operations uncertain. 

The results following the examination of the urine and the 
circulation enables the surgeon intelligently to select the 
proper anesthetic. The condition of the bowels should also 
be investigated. If constipation exists it should be relieved 
by mild cathartics; free purgation should be avoided. It is 
customary to give a laxative the night before operation and 
a saline or an enema in the morning. Emptying the bowels 
lessens the liability of wound infection, and an empty lower 
bowel is of great value if it becomes necessary to give stimu- 
lants by enema during or after the operation. In operations 
upon the anus, rectum or colon I prefer to have the bowels 
opened freely on the day preceding the operation, for if it is 
postponed until the day of operation the manipulations are 
often followed by fecal discharges, which soil the wound and 
cause unnecessary delay. The diet should be regulated so 
that bland and nutritious articles of food only are allowed. 
It is customary in most hospitals to put a sterilized operating 
suit upon the patient before going to the operating-room. 
This is usually made of canton flannel. If the patient has 
been in the habit of wearing woolen underwear it is well to 
apply a freshly laundried woolen undershirt to protect the 
chest rather than to change to a muslin one, for I am con- 
fident that many of the pulmonary complications attributed 
to the operation and anesthetic are due to neglect of this 
precaution. 



424 ASEPSIS AND ANTISEPSIS 

Preparation of Room. — In hospital practice suitable opera- 
ting-rooms are provided; in private practice, however, the 
surgeon is often called upon to select a room and give direc- 
tions as to its preparation. A well-lighted room should 
always be selected and all unnecessary articles of furniture, 
such as ornaments, pictures and curtains, should be removed. 
The carpet should be taken up and the floor scrubbed. A 
few small tables and a large wooden table should be placed 
in the room, having previously been dusted and wiped off 
with a bichloride solution. All preparations should be made, 
if possible, upon the day before the operation, as the stirring 
up of dust incidental to the change in furniture in cleaning 
the room on the day of operation immediately before the time 
set is more dangerous than no cleaning of the room whatever, 
since the principal contamination of the wound is likely to 
come from germs contained in the dust. In cases of emer- 
gency the floor may be well moistened by sprinkling with 
water to lay the dust or covered by sheets wrung out of 
bichloride solution. The preparation of the room is not, in 
my judgment, a matter that affects the results of operations 
as much as does the exercise of great care in regard to aseptic 
details of the operation itself. 

Preparation of Field of Operation. — The skin always contains 
microorganisms, which develop upon it and are constantly 
being deposited upon it from the air. We can scarcely hope 
to obtain absolute sterilization of the skin under these circum- 
stances, but by careful preparation seek to obtain that rela- 
tive sterility which enables us to obtain primary union. The 
patient should be given a general bath the night before the 
operation, and the skin surrounding the site of operation 
should be thoroughly scrubbed with a brush and soap and 
water; or a soap poultice may be applied to the part for a 
few hours before the final sterilization with alcohol and 
bichloride is made. In scrubbing the skin a soft brush should 
be used, since too forcible scrubbing may cause irritation or 
dermatitis. After this scrubbing has been continued for a 
few minutes the skin is washed with alcohol and ether, then 
douched with sterilized water, and there should be applied 
to the surface a folded towel or gauze dressing saturated with 
a 1 : 1000 bichloride solution; or if a moist dressing is uncom- 



PREPARATION FOR ASEPTIC OPERATION 425 

fortable to the patient a few layers of sterilized gauze should 
be placed over the surface and held in place by a bandage. 
A similar washing and preparation of the seat of operation 
should be made the next morning, a few hours before the time 
fixed for operation. 

Sterilization of the skin by tincture of iodine is now fre- 
quently employed. In emergency cases, where the prepara- 
tion of the field of operation is made in the operating-room, 
the skin is first rubbed over with benzine or alcohol and 
ether, which dissolves oily substances and evaporates rapidly, 
leaving the skin dry for the application of the iodine. The 
skin should be dry shaved, should be dry, and in emergency 
cases 3 to 5 per cent of tincture of iodine in alcohol is 
painted directly over the field of operation without prelimi- 
nary washing of the skin. Where there is time the surface is 
painted with iodine some hours before the operation, and 
another application is made just before the operation is under- 
taken. At this time the area covered with iodine may be 
freed of iodine by wiping it with a gauze pad saturated with 
alcohol. 

Tincture of iodine should not be used upon the genitals 
or the scrotum. 

The skin may also be sterilized by formalin. It should first 
be scrubbed thoroughly with soap and water, and then a few 
layers of gauze saturated with a 1 per cent solution of forma- 
lin should be laid over it and covered by an impermeable 
dressing. This solution should be kept in contact with the 
skin for twenty-four or thirty-six hours, the compress being 
changed every twelve hours. Picric acid in a 2 to 5 per cent 
alcoholic solution may also be used to sterilize the skin. 

It is well to remember that regions of the body which con- 
tain hair and numerous sweat glands, such as the axilla, 
navel, scrotum, groin and the creases about the joints, are 
those in which microorganisms grow with the greatest activ- 
ity. All the surrounding hair should be shaved off; and if the 
operation be upon the skull it is well to shave the scalp 
completely. 

Sterilization of the Feet. — There is usually present upon the 
feet a large amount of thickened epidermis which renders 
their sterilization difficult. The feet should be washed thor- 



426 ASEPSIS AND ANTISEPSIS 

oughly with soap and water and scrubbed vigorously with a 
brush; or a soap poultice should be applied to the whole 
surface of the feet for some hours and held in position by a 
bandage. A moist dressing favors separation of the super- 
ficial layers of the epidermis, and after it has been worn for 
a few hours it is possible to remove a large amount of the 
latter by the use of the brush. After having been washed 
thoroughly with a 1 : 1000 bichloride solution they should be 
be wrapped in a towej or a few layers of gauze saturated 
with bichloride of mercury solution, 1 : 1000. Or after being 
washed with green soap and water they are dried and a dry 
gauze dressing is applied for some hours. When the skin is 
perfectly dried it may be sterilized by painting it with tincture 
of iodine. 

Sterilization of the Vagina. — The vagina and external geni- 
tals require great care in their sterilization. According to 
Schimmelbusch, the best method of sterilizing the vagina is 
to dilate it fully with a speculum and to scrub it thoroughly 
with pads of gauze saturated with green soap and water, and 
after this cleansing, to irrigate it with a 1:2000 bichloride 
solution or a 1 per cent solution of creolin. 

Sterilization of the Bladder and Urethra. — It is impossible to 
sterilize completely the mucous membrane of the bladder. 
The bladder should be emptied by catheter and irrigated with 
sterile water or normal salt solution. The best means we 
have at our disposal at the present time of sterilizing the 
mucous membrane of the bladder consists in irrigating the 
organ frequently with a 15-grain to the ounce solution of 
boric acid in boiled water. In operations upon the urethra 
the same care should be taken to render the urethra sterile by 
free irrigation with normal salt solution or boric acid solution. 

Sterilization of the Stomach. — The stomach should be steril- 
ized by thorough lavage with normal salt solution or boric 
acid solution. This is important, not only in operations upon 
the stomach itself, but also in operations upon the pharynx, 
to diminish the risk of infection by vomited matter. In 
cases of intestinal obstruction with vomiting, lavage of the 
stomach should always be employed before operation. 

Sterilization of the Rectum. — When an operation is to be 
performed upon the anus and rectum the patient should be 



PREPARATION FOR ASEPTIC OPERATION 427 

given a purgative and an enema the day before the operation 
to remove any fecal matter which may be in the rectum. The 
region of the anus should be shaved, disinfected with soap 
and water and thoroughly scrubbed, and after the patient 
has been anesthetized the sphincter should be well stretched 
and the rectum irrigated with a boric acid solution, or a 1 
to 3 per cent creolin solution. A tampon of sterilized gauze, 
with a string attached, may be packed into the rectum above 
the seat of operation to prevent the wound from becoming 
soiled with feces during the operation. The tampon can be 
removed by means of the string after the operation has been 
completed. 

Sterilization of the Scalp. — Great care should be observed 
in sterilizing the scalp before operations on the scalp or brain, 
as the scalp is often covered by dense masses of epidermis. 
The entire scalp should be shaved and a soap poultice applied 
for twelve hours, or the application of sweet oil for twenty- 
four hours before the use of the soap poultice may be of use 
in softening the epidermis. It should be rubbed thoroughly 
with soap and water and finally with a 1:1000 bichloride 
solution or a 2 to 5 per cent alcoholic picric acid solution may 
be employed. 

Sterilization of the Mouth and Nasal Cavities. — To render the 
mouth as far as possible sterile the teeth should be thoroughly 
brushed with tooth powder and the cavity of the mouth 
frequently rinsed with a solution of peroxide of hydrogen, 
1 part to 6 parts of water, or with a saturated solution of 
boric acid. The nasal cavities and the postnasal region 
should be sterilized by spraying them with the same solution 
or with Dobell's or normal salt solution. 

Sterilization of the Hands. — The difficulty of completely 
sterilizing the hands has been shown by bacteriological tests, 
for it has been demonstrated that after great care in the 
process complete sterility could be obtained only in about 95 
per cent of the tests. The hands of the surgeon, unless pro- 
perly sterilized, may be the most efficient agents in producing 
infection of the wound; the region of the finger-nails and the 
interdigital folds are locations where germs are particularly 
abundant. The hands and forearms of the surgeon, assist- 
ants and nurses, who are to take part in the operation, may 



428 ASEPSIS AND ANTISEPSIS 

be sterilized by first rubbing them with spirit of turpentine, 
and then thoroughly scrubbing them with Castile soap and 
water, using a nail-brush freely. Care should be taken that 
the brush is sterilized. This scrubbing should be employed 
for several minutes (five to ten minutes) ; the hands and fore- 
arms are then rinsed to remove the soap and are soaked for 
two minutes in a 1 : 1000 bichloride of mercury solution. If 
turpentine has not been employed before washing with the 
soap strong alcohol, benzine or ether should be rubbed well 
over the hands before they are immersed in the bichloride 
solution. When the hands have been sterilized they should 
not be brought in contact with anything that is not sterile. 

Harrington's Method. — Harrington, after washing the 
hands thoroughly with green soap, immerses them in the 
following solution for a few minutes: alcohol (94 per cent), 
640 cc; hydrochloric acid, 60 cc; water, 300 cc; corrosive 
sublimate, 0.8 gm. This solution has been found to be a most 
efficient sterilizing agent. 

Chloride of Lime and Carbonate of Sodium. — Weir recom- 
mends the following method of sterilizing the hands. After 
washing them with green soap put a tablespoonful of com- 
mercial chloride of lime and an equal amount of crystalline 
carbonate of sodium (washing soda) in the hand with enough 
water to make a paste. Rub this into a thick cream, which 
should be rubbed into the hands until the grains of lime 
disappear and the skin feels cool. The hands are then rinsed 
in sterile water. This method of sterilization of the hands 
has, in my experience, been most satisfactory. If employed 
several times a day irritation of the skin may result. 

Sterilization of Instruments. — The sterilization of instru- 
ments may be accomplished by dry or moist heat; they 
should be placed in a hot-air sterilizer or baked for twenty 
minutes in a hot oven. Sterilization of instruments by dry 
heat or baking is not often employed, as it is apt to spoil the 
temper of the steel. Instruments may be sterilized by the 
method suggested by Schimmelbusch, now almost universally 
employed, which consists in boiling them for fifteen minutes 
in water to which a tablespoonful of washing soda (carbonate 
of sodium) has been added for each quart of water; this 
prevents the rusting of the instruments, and also makes the 



PREPARATION FOR ASEPTIC OPERATION 429 

water a better solvent for any fatty matter which may be 
upon the instruments, thus increasing the sterilizing effect of 
the heat. If wooden-handled instruments are used (it is 
better not to use instruments of this kind), which would be 
injured by boiling, they should first be thoroughly scrubbed 
with soap and water and a brush, and after having been rinsed 
in sterilized water they should be placed in a tray and covered 
with 1 : 20 watery solution of carbolic acid, and allowed to 
remain in this solution for at least half an hour; before being 
used they should be transferred to a bath of sterilized water, 
which will prevent the benumbing effect of the carbolic 
solution upon the surgeon's hands. 

A frequent boiling injures the cutting edge of knives; they 
may be rendered sterile by first thoroughly washing them 
and placing them in pure carbolic acid for from three to five 
minutes, then transferring them to a vessel containing alcohol. 

Instruments may also be sterilized by formalin : The latter 
is generated by heating pastilles of paraform with Schering's 
formalin lamp. The instruments are placed in racks in a 
metal case, and by burning from 10 to 15 grains of paraform 
the instruments may be rendered sterile in fifteen minutes. 

Instruments which fall upon the floor or come in contact 
with the clothing of the surgeon or of the patient during the 
operation should again be sterilized before being brought in 
contact with the wound. 

Sterilization of Catheters and Bougies. — These, if made of 
metal or glass, may be sterilized by boiling for ten minutes in 
a 1 per cent solution of sodium carbonate. If constructed of 
gum prolonged boiling destroys them; these may, however, 
be sterilized by first washing them with soap and water, and 
then placing them for fifteen minutes in a 1 per cent solution 
of sodium carbonate, heated nearly to the boiling-point; they 
are next placed in a 1 : 1000 bichloride solution until required. 
They should, on being removed from this solution for use, be 
soaked thoroughly in hot sterile water to remove all the 
bichloride solution. Rubber catheters may be sterilized by 
boiling, they may also be sterilized by soaking them for an 
hour in a 2 per cent solution of formalin. For lubricating 
catheters and bougies sterilized olive oil, liquid vaseline or 
K. Y. should be employed. 



430 ASEPSIS AND ANTISEPSIS 

Rubber Gloves. — These gloves are now extensively em- 
ployed in operative work, and the results following their 
use have been most satisfactory; they protect both the 
patient and the surgeon from infection. They are made of 
very thin rubber, so that there is little interference with 
tactile sensation, and from their elasticity they fit the hands 
accurately. They can be rendered absolutely sterile, and as 
they are impervious to moisture there is no risk of wound 
infection if the hand is not completely sterilized unless the 
gloves have been torn or punctured during the operation. 
A punctured rubber glove is more dangerous than the bare 
hand, from the fact that moisture or sweat from the hand 
may escape through the puncture. To avoid this possibility 
of infection the hands should be sterilized as completely as 
possible before they are applied. They may be sterilized by 
first washing them with soap and water, and then wrapping 
them in a towel and boiling them for thirty minutes in a 1 
per cent solution of carbonate of soda. They may be applied 
by filling them with sterilized water or salt solution, and 
then introducing the hand. In operating upon patients with 
infected wounds or in dressing infected wounds rubber 
gloves should always be worn. If properly cared for a pair 
of gloves will withstand a number of sterilizations. A freshly 
sterilized pair of gloves should be used for each operation. 
At the present time the use of gloves which have been steril- 
ized and dried is considered safer; the gloves and hand are 
dusted with sterile talcum powder before they are applied. 

Clothing of Surgeon and Assistants. — The surgeon and his 
assistants should wear sterilized linen or muslin suits, or be 
provided with gowns with sleeves reaching to the wrists for 
the protection both of the patient and of their clothing. 
The operating gown should be made of muslin or linen with 
sleeves reaching to the wrist, which can easily be sterilized by 
boiling or heat; a variety of linen known as butchers' linen 
is very serviceable for this purpose. As a matter of addi- 
tional precaution, many surgeons and their assistants wear 
during the operation closely fitting skull caps of linen or 
gauze, and wear over the nose and mouth a mask or a pad 
composed of a number of layers of sterilized gauze to prevent 
infection of the wound by the expired air. The surgeon and 



DETAILS OF AN ASEPTIC OPERATION 431 

assistants will often find it convenient to wear under their 
linen gowns India-rubber aprons to prevent soiling of the 
clothing by blood or solutions. The nurses should wear 
sterilized linen or muslin operating gowns and dresses of 
washable goods. An operating apron may be improvised from 
a clean sheet folded so as to be 1 J yards in width and from 5 
to 6 feet in length, by turning in about 10 inches of one end 
of the sheet over the upper part of the chest and placing a 
strip of bandage in this fold, which should be secured around 
the neck and tying a second strip of bandage over the sheet 
at the waist. 

The number of instruments, gauze sponges and pads 
allotted for each operation should be recorded, and before the 
wound is closed they should be counted. This is especially 
important in abdominal operations. The care of sponges 
and pads is the special duty of one nurse. 

Details of an Aseptic Operation. — The patient being pre- 
pared for operation as described, and having been anes- 
thetized, is placed upon the operating table, the surgeon, 
assistants and nurses also being prepared for the operation 
as previously described. If the operation be one upon the 
face, neck or chest it is well, before the dressings covering the 
seat of operation are removed, to cover the patient's hair 
with a rubber bathing cap or a towel or handkerchief bandage 
made of several layers of sterilized gauze. The portions of 
the patient's body which it is not necessary to expose in the 
operation should be covered with a woolen blanket, and this 
covered with a sterilized sheet. Some surgeons prefer to 
have the patient wear a sterilized gown which is ripped or cut 
to expose the part to be operated upon. The region of the 
wound and the operating table are next protected with steril- 
ized sheets and towels. Black sheets surrounding the wound 
have been recommended by some surgeons with the idea 
that the glare from white sheets interferes with accurate 
inspection of the wound during the operation. The surgeon 
having assigned the assistants and nurses their duties, the 
dressing is removed from the part to be operated upon, and 
the operation is begun. Hemorrhage is controlled by the use 
of hemostatic forceps and sterilized gauze sponges are 
employed to keep the wound free from blood. When the 



432 ASEPSIS AND ANTISEPSIS 

operation is completed the vessels are ligated, the hemostatic 
forceps are removed and the wound is dried with gauze 
sponges. If, for any reason, the surgeon deems it advisable 
to irrigate the wound, it may be done with hot sterilized 
water or with sterilized salt solution. In operations involv- 
ing the abdominal cavity the greatest care should be taken 
to see that no instrument, sponge or gauze pad is left in the 
cavity before the wound is closed. If the surgeon decides 
that drainage is not necessary the deeper parts of the wound 
may then be brought together with buried sutures of catgut 
or silk to approximate tissues and eliminate dead spaces, and 
the edges of the superficial wound next approximated by 
sutures of catgut, silk or silkworm gut. If the surgeon 
decides to use drainage before closing the wound a few strands 
of catgut, a strip of sterilized gauze, a tent of rubber tissue 
or a rubber drainage tube is introduced into the "deepest 
portion of the wound and brought out at its most dependent 
part. The wound is then dressed with a number of loose 
masses or pads of sterilized gauze placed so as to cover the 
wound and extend beyond it in all directions. Over the gauze 
dressing are placed a few layers of sterilized cotton, extending 
on all sides well beyond the gauze, and the dressings are held 
in place by a sterilized gauze bandage or adhesive straps. 
The dressings should be voluminous; it is always a mistake 
to apply scanty dressings. In redressing the wound the same 
care should be exercised as regards asepsis as was observed 
at the primary dressing. 

Postoperative Treatment. — Recovery from a general anes- 
thetic is considered on p. 239. After the patient has recovered 
from the anesthetic he should be kept quiet and free from 
excitement and encouraged to sleep. If pain is present it 
should be relieved by the judicious use of codeine or morphine. 
The dressings should be inspected to see that they are in 
place and that there is no bleeding. Patients often complain 
of thirst, but if given water by the mouth are apt to vomit; 
so it is better allayed by giving water by the rectum for the 
first twelve hours. As a rule, no food is required for twelve 
or twenty-four hours, and then liquid diet, albumin water, 
broth or milk may be given. Persistent vomiting of sour 
liquid after operations call for an examination of the urine 



DETAILS OF AN ANTISEPTIC OPERATION 433 

for acetone. Postoperative retention of urine is not uncom- 
mon in males but is rare in women. If no urine is passed in 
twelve hours the condition of the bladder shall be investi- 
gated. If the bowejs are not moved spontaneously in forty- 
eight hours an enema or a laxative should be administered. 

The redressing of the wound if drainage has been employed 
should be done on the second day and the drainage removed 
at this time if there is no further indication for its use. It 
is well not to bring even the gloved hands in contact with 
the wound or dressings, but to use forceps to handle the 
dressings. If drainage has not been used and the wound is 
running an aseptic course it need not be dressed for from eight 
to ten days, and at this dressing the sutures should be 
renewed. 

Details of an Antiseptic Operation. — The region of the wound 
being previously sterilized and the patient being anesthetized 
and placed upon the table, the clothing is so arranged as to 
expose freely the part to be operated upon; the clothing or 
skin surrounding this region is next covered with towels wet 
with a 1 : 1000 bichloride solution. If any considerable sur- 
face of the patient's body is covered by these towels, to avoid 
chilling the surface and adding to the shock which naturally 
follows the operation, they should be wrung out in a hot 
bichloride solution, and should be replaced as they become 
cold by hot towels prepared in the same manner. 

During the operation the wound may be irrigated with a 
1 : 2000 to 1 : 4000 bichloride solution. In prolonged opera- 
tions, or in those in which a large wound is made, it is espe- 
cially important that the irrigating solutions should be used 
as warm as can comfortably be borne by the hands of the 
surgeon; warm solutions, it has been shown by recent investi- 
gations, possess a greater germicidal power than those of the 
same strength when used cold, and they also possess the 
advantage of preventing chilling of the patient, and thus 
diminish the shock of the operation. 

Hemorrhage during the operation is controlled by the use 
of hemostatic forceps. After the operation has been com- 
pleted, and all hemorrhage has been controlled, the wound is 
thoroughly irrigated with a 1 ■ 4000 to 1 ; 2000 bichloride 
solution. 
28 



434 ASEPSIS AND ANTISEPSIS 

Drainage is provided for by the use of perforated rubber 
drainage tubes or strips of gauze. 

The rubber tube may be laid in the wound, the ends being 
allowed to extend from the extremities of the wound, or it 
may be so introduced that one end of the tube rests in the 
deepest part of the wound and the other extremity is brought 
out of the wound at its most dependent portion; in large or 
irregularly shaped wounds a number of tubes may be required 
to secure free drainage. The ends of the drainage tubes are 
transfixed with safety pins which have been sterilized or 
secured by a suture to the skin, and should next be cut off 
close to the pins or suture so as to be as nearly as possible 
flush with the skin. 

The wound being closed by sutures, a final irrigation of its 
deepest parts should be made by injecting a stream of bichlo- 
ride solution, 1 : 4000 to 1 : 2000, into the end of the drainage 
tube. Over this is laid the deep dressing, which consists of 
a pad of bichloride gauze from eight to sixteen layers in 
thickness, and large enough to overlap the wound 2 or 3 
inches in all directions. This should be dipped in a 1 : 4000 
to 1 : 2000 bichloride solution, and wrung out as dry as 
possible before being applied. The superficial bichloride 
gauze dressing is next applied, and consists of sixteen layers 
of gauze, which should be large enough to extend from 3 to 6 
inches beyond the wound in all directions; this gauze is 
applied dry. Over the superficial gauze dressing there is 
next applied a number of layers of sterilized cotton, so 
arranged as to extend a little beyond the margin of the gauze 
dressing. These dressings are next secured in position by 
the application of a gauze bandage or adhesive straps. Iodo- 
form, carbolized or any other variety of medicated gauze may 
be used in place of the bichloride gauze. 

The dressing of the wound should be made with the great- 
est care as to asepsis. The bandage should be cut and 
removed and dressings removed by forceps, and the skin 
surrounding the wound covered with sterile towels. Rubber 
gloves should be worn and the dressings should be handled 
with forceps. The drainage tube is usually required for 
some days, but if there is no further indication for drainage 
it should be removed. 



REDRESSING OF THE WOUND 435 

Redressings of the Wound. — If the wound is not running the 
typical course of an aseptic wound, constitutional symptoms 
will be developed, as evidenced by a rise in the temperature 
and pulse-rate and other constitutional disturbances. In 
this event the wound should be redressed as soon as possible, 
and if the cause of the disturbance can be found it should be 
removed; for instance, hemorrhage may have taken place 
into the wound, and the blood not being able to escape 
through the drainage tubes may have caused so much disten- 
tion of the wound that the vitality of the skin covering the 
wound is threatened, or the sutures may be found to be 
causing irritation or suppuration may be present. 

If, on exposure of the wound, it is found that it is distended 
with blood clots, and that blood is escaping from the wound, 
the sutures should be removed, the clots turned out and the 
bleeding vessel or vessels sought for and ligatured, and the 
wound, after a thorough irrigation with saline solution, should 
be drained and closed with sutures and dressed as previously 
described. 

If, however, on exposure of the site of the operation, and 
upon the removal of a portion or all of the sutures, the wound 
is found distended with a blood clot, and no evidence of 
hemorrhage at the time exists or of suppuration in the wound, 
the clot may be allowed to remain in place and the wound 
should be redressed as in the original dressing, trusting to 
the organization of the blood clot if it has remained aseptic. 
If the patient's condition improves after the dressing, and the 
temperature and pulse-rate become normal it is an indication 
that the wound is still aseptic, and it need not be redressed 
for some days. 

If, on the other hand, examination of the wound shows that 
the drainage is insufficient, or that the drainage tubes are 
occluded by blood clots, these should be removed by washing 
out the tubes with saline solution by means of a syringe, and 
introducing additional drainage tubes if it is deemed neces- 
sary; the wound should then be redressed. 

When it is found on examination of the wound that suppu- 
ration is present the sutures should be removed, the wound 
opened up and Carrel-Dakin treatment applied. If the con- 



436 ASEPSIS AND ANTISEPSIS 

stitutional symptoms improve it may be assumed that the 
wound has been rendered aseptic. 

Antiseptic Treatment of Infected Wounds. — It often happens 
that the surgeon is called upon to treat a wound which is 
septic when it comes under his care, as evidenced by the 
inflamed state of the wound, inflammation of the lymphatic 
vessels and skin, foul discharges and sloughing of the tissues, 
and the coexistent constitutional symptoms of sepsis. In 
such a case it would at first sight appear that the surgeon or 
his assistants could not introduce any infection worse than 
that which already existed in the wound, but he should bear 
in mind the fact that it is possible to introduce a new form 
of infection in addition to that already existing. With this 
possibility in view he should observe the same precautions 
as regards the sterilization of his hands, the region of the 
wound, the instruments and dressings, as he would employ in 
treating a perfectly fresh wound. 

The most important part of the treatment of infected 
wounds is free drainage. The skin surrounding the wound 
should be dried by washing it with ether or benzene and 
tincture of iodine should next be applied. Free drainage is 
secured by the introduction of rubber drainage tubes or gauze 
wicks. The wound before the drainage is introduced should 
be flushed with peroxide of hydrogen followed by saline solu- 
tion or 1 : 2000 bichloride solution. Moist antiseptic dress- 
ing, gauze saturated with saline solution or bichloride solu- 
tion, should next be applied and changed every three or four 
hours. The constitutional condition of the patient should 
also receive attention. Formerly the use of a 30-grain solu- 
tion of chloride of zinc swabbed over the surface of the wound 
or a 2 per cent solution of formalin followed by moist anti- 
septic dressings was often employed with good results. At 
the present time the instillation of Dakin's solution by the 
Carrel-Dakin method is the treatment generally employed 
and is most efficient in these cases. The dichloramine-T 
dressing may also be used with good results. By these 
methods of treatment it is often possible to convert a septic 
wound into the aseptic one and have rapid improvement 
follow both in the local condition of the wound and in the 
constitutional condition of the patient. 



PART IV. 
FRACTURES. 



In the following section the author has endeavored to con- 
fine himself simply to a description of the varieties of fracture 
and to their dressing and treatment, and he has tried as far 
as possible to avoid the multiplication of dressings, being 
satisfied to describe a few of the methods of dressing most 
frequently employed. He has also avoided the description 
of complicated splints and dressings, by the use of which in 
certain fractures most excellent results are obtained, but has 
preferred to recommend the employment of simple splints 
and dressings, which can be obtained by physicians practising 
in districts remote from large cities, where the services of an' 
instrument maker cannot be obtained to construct special 
apparatus for the treatment of these injuries. The recently 
introduced suspension traction treatment of fractures of the 
long bone is described. 

Varieties of Fractures. — Complete Fracture.— This is a frac- 
ture in which the line of separation completely traverses the 
bone, involving its entire thickness. 

Incomplete Fracture.- — This is a fracture in which there is 
only a partial separation of the bone fibers (Fig. 266), under 
which name is included partial or "green-stick" fracture, in 
which some of the bone fibers have given way, while the 
remaining fibers have been bent by the force, but have not 
been broken (Fig. 267). Fissured, punctured, indented and 
perforating fractures are also included in the class of incom- 
plete fractures (Fig. 268). 



438 



FRACTURES 



Subperiosteal Fracture. — This is a fracture in which the 
fibers of the bone are ruptured but the periosteum remains 
untorn; it is seen in infants and young children. 

Gunshot Fractures.- — The nature of the injury to the bone 
depends upon the density of the latter, and upon the size, 
shape, composition and velocity of the ball. In gunshot 



Fig. 266. 



Fig. 267. 



Fig. 268. 




Incomplete fracture 
of femur. 



Partial or green-stick 
fracture of radius. 



Fissured fracture 
of the humerus. 



injury of the spongy bones the cancellated structure yields 
to pressure, and the striking energy is not transmitted in 
lateral directions, producing explosive effects; while in the 
dense bones, such as the submaxillary bones or the shafts 
of the long bones, extensive comminution and Assuring are 
apt to result. In the articular ends of the long bones clean 
perforations are often observed, except at close range, when 



VARIETIES OF FRACTURES 



439 




Fig. 270. 



more or less comminution of the cancellated structure may 
occur. The tissues from the wound of entrance to the bone 
are usually injured only in the line of perforation, but those 
beyond the seat of injury are often extensively lacerated and 
contused, not only by the ball, but also by the splinters of 
bone driven into the tissues and acting as secondary missiles. 

Simple or Closed Fractures. — 
This is a fracture in which there 
are but two fragments, and the 
seat of injury in the bone does 
not communicate with the ex- 
ternal air by a wound in the 
soft parts. 

Compound or Open Fracture. — 
This is a fracture in which the 
seat of injury in the bones com- 
municates with the external air 
by a wound in the soft parts. 

Comminuted Fracture. — This 
is a fracture in which there are 

Fig. 269. 




Comminuted fracture of patella. 



Multiple fracture of the upper 
extremity. (Ashhurst.) 



more than two fragments, the lines of fracture intercom- 
municating with each other (Fig. 269). 

Multiple Fracture. — This is a fracture in which a bone is 
the seat of two or more distinct fractures at different points, 
the lines of fracture not necessarily communicating with each 
other. (Fig. 270). 



440 



FRACTURES 



Complicated Fracture. — This is a fracture accompanied by 
some serious injury of the parts in the region of the fracture 
— as, for instance, the laceration of important bloodvessels 
or nerves, contusion or laceration of the muscles or dislocation 
of a neighboring joint. 

Impacted Fracture. — This is a fracture in which one frag- 
ment is driven into and fixed in the other, the impaction 
taking place at the time of frac- 
ture, or being caused by a force FlG - 272 - 
subsequently applied (Fig. 271). 

Transverse Fracture. — This is a 
fracture in which the general line 
of division of the bone is at right 
angles with the long axis of the 



Fig. 271. 




m§ 



s\ 



Impacted fracture. 



Transverse fracture of femur. 



bone (Fig. 272) . Transverse fractures of the long bones are 
rarely met with, the line of fracture usually being more or 
less oblique. 

Oblique Fracture. — This is a fracture in which the line of 
separation is oblique to the long axis of the bone. This is 
one of the most common directions of the line of fracture 
(Fig. 273). 



PROGNOSIS OF FRACTURE 



441 



Longitudinal Fracture.- — This is a fracture in which the line 
of separation runs in the general direction of the long axis 
of the bone (Fig. 274) . This form of fracture is rare, but is 
sometimes met with in the long bones as the result of gunshot 
injury. 

Symptoms of Fracture. — The most prominent symptoms 
of fracture are loss of function, deformity, preternatural 



Fig. 273. 



Fig. 274. 




Oblique fracture of humerus. 



Longitudinal fracture of tibia. 



mobility, pain, crepitus and muscular spasm. In impacted 
fractures, crepitus and preternatural mobility are absent. 

Prognosis of Fracture. — This is good as far as the patient's 
life is concerned; the general mortality in a large series of 
statistics is about 2.5 per cent. Compound and complicated 
fractures have a much higher mortality, about 25 per cent. 

Death following fractures may result from shock, hemor- 



442 FRACTURES 

rhage, visceral injuries, embolism, delirium tremens and fat 
embolus and in the aged from exhaustion. 

Deformity. — The deformity or displacement in fractures is 
either angular, transverse, longitudinal or rotary. 

Examination of Fractures. — In examining a case of fracture 
to locate the nature and seat of the injury the clothing should 
be removed from the part with as little disturbance as 
possible, and it is better in most cases to cut or rip the 
clothing rather than to attempt to remove it in the ordinary 
manner. The surgeon should first inspect the injured part 
and where possible compare it with its fellow, as in the case 
of injuries of the extremities; much valuable information is 
also derived from the patient or his friends as to the manner 
in which the injury was produced. The part should next be 
carefully examined by the surgeon; if it be one of the extrem- 
ities which is injured it should be gently lifted, firm extension 
being made at the same time, the surgeon by his touch and 
by gentle movements seeking to locate the seat of fracture; 
and he may, by his manipulation, at the same time develop 
crepitus. 

All manipulations should be made with care, and with the 
greatest gentleness, not only to save the patient from pain, 
but also to prevent the soft parts in the region of the fracture 
from being injured by the rough or sharp fragments of the 
bone. Rough handling of fractures may increase the mus- 
cular spasm by the irritation caused by the sharp fragments 
of the bones and may also result in the injury of important 
vessels and nerves, and indeed a simple fracture may easily 
be converted into a compound one by forcible and injudicious 
manipulations. 

The sooner the examination is made after fracture has 
occurred the better, for at this time there is less swelling in 
the region of the injury, and the surgeon can locate the bony 
prominences with much more ease and often discover the 
exact seat of the fracture with the least amount of manipula- 
tion of the parts. When a case of suspected fracture is not 
subjected to examination for several days after reception of 
the injury, the parts in the region of the supposed fracture 
are often so much swollen that it is impossible to accurately 



REPAIR OF FRACTURES 443 

locate its seat, and in such a case a roentgen-ray examination ' 
should be made. 

Anesthetics in Examination of Fractures. — These may be 
employed to relieve the patient from pain and to obliterate 
muscular spasm in the examination of fractures. Their 
employment is often of the greatest service in the diagnosis 
of obscure or complicated fractures, especially those in the 
neighborhood of joints; but the surgeon should remember 
that all manipulations should be made with the same gentle- 
ness as when the examination is conducted without anes- 
thesia, for there is the same risk of injury to the surrounding 
structures by the fragments; this precaution is often neglected 
when an anesthetic has been given, the surgeon being inclined 
to handle the parts more roughly than he otherwise would; 
such practice cannot be too severely condemned. 

Ether is the most satisfactory anesthetic for this purpose 
as by its use complete relaxation may be obtained, but 
nitrous oxide may be used. 

Roentgen-ray Examination. — This method of examination 
is now very widely employed in fractures. The use of the 
fluoroscope or of a roentgenograph taken by the roentgen rays 
has proved a valuable means of ascertaining the existence, 
location and nature of the fracture in obscure cases. It is 
advisable in every case of fracture where it is possible to have 
an roentgen-ray examination and if possible to have another 
examination after the case has been under treatment for a 
short time to ascertain if the fragments are in good position. 
This form of examination has done much to increase our 
knowledge of fractures. By this method of examination we 
have learned that comminution is much more common in 
fractures than was generally supposed. Distortion of the 
image sometimes occurs from the direction in which the rays 
are applied, and this fact should not be lost sight of in examin- 
ing roentgen-ray plates. 

Repair of Fractures. — Bone reacts to injury or disease in 
much the same way as the other tissues, but the phenomena 
of inflammation and repair are less active and slower than in 
the soft tissues. When a bone is fractured the surrounding 
soft parts are more or less damaged and react to the injury 



444 FRACTURES 

by the process of inflammation. A blood clot forms in the 
medullary cavity, between the broken ends and under and 
outside of the periosteum. Various cellular tissues in the 
injured region; bone cells from the marrow and periosteum, 
muscle cells, connective-tissue cells and leukocytes proliferate 
and aid in removing debris and cause organization in the 
mass of inflammatory lymph which is formed. The inter- 
cellular substance of the bone is temporarily absorbed on 
removal from the fractured ends by osteoclasts and the exu- 
date forming between the fragments, which is known as 
callus, is analogous to the inflammatory lymph which sur- 
rounds it or with which it is continuous. During the regen- 
eration the bone ends soften and are partly absorbed by osteo- 
clasts. This callus is derived largely from the medulla of 
bone by proliferation of osteoblasts. In the course of two 
weeks the callus, after passing through a cartilaginous 
stage, becomes impregnated with lime salts. The callus as 
organization proceeds gradually becomes condensed, the 
central callus is not entirely absorbed and complete restora- 
tion of the medullary canal is rare. The process of repair 
begins a few days after the occurrence of fracture. In simple 
fractures union is usually firm in four weeks, but in com- 
pound and comminuted fractures union is often much 
delayed. 

Provisional Dressings of Fractures. — It generally happens 
that fractures occur at localities more or less distant from 
the point where the treatment of the fracture is to be con- 
ducted and the transportation of the patient and the tempo- 
rary dressing of the fracture are, therefore, matters of the 
first importance. In fractures of the upper extremity, if the 
fractures be simple, the clothing need not be removed, and 
the arm should be bound to the side by some article of cloth- 
ing, or supported in a sling made from handkerchiefs or the 
clothing, and the patient can usually walk or ride for a short 
distance without much injury to the parts in the region of the 
fracture or inconvenience to himself. When the bones of 
the lower extremities or the trunk are the parts involved, the 
transportation of the patient is a matter of more difficulty. 
When the bones of the trunk are involved, the part should be 



TRANSPORTATION OF FRACTURES OF EXTREMITIES 445 



Fig. 275. 



surrounded by a binder firmly pinned or tied, made from 

clothing or from towels or sheets or other strong materials 

which are at hand. When the bones of the lower extremity 

are involved, if the fracture be a simple one the clothing need 

not be removed, and the motion of the fragments should be 

prevented by applying to the sides of the limb, extending 

above and below the seat of fracture, strips of wood, shingles, 

pasteboard, bundles of straw, 

strips of bark taken from trees 

or bundles of twigs, these being 

held in place by handkerchiefs 

or strips torn from the clothing 

(Fig. 275). Umbrellas or canes 

or broomsticks applied in the 

same manner may be employed, 

the object of all of these dressings 

being to secure temporary fixation 

of the fragments of bone during 

the transportation of the patient. 

Transportation of Fractures of 
the Extremities. — The use of 
Thomas' splints for the trans- 
portation of fractures of the upper 
or lower extremity is most satis- 
factory. For transporting a frac- 
ture of the lower extremity the 
Thomas knee splint (Fig. 276) 
is employed and for those of the 
upper extremity the Thomas 
humerus splint (Fig. 277) is 
used. Temporary extension at 
the same time may be made by 

applying a band around the wrist or ankle and securing it 
to the loop at the end of the splint. The results following 
this method of temporary fixation and extension have been 
so satisfactory that the majority of hospital ambulances are 
equipped with these splints. 

If the fragments are not fixed in some way, but are allowed 
to move about during the transportation of the patient, 




Provisional dressing for fractreu 
of the leg. 



446 FRACTURES 

much damage may result to the soft parts surrounding the 
fractured bones, and simple fractures may become com- 
pounded ones by the bones being forced through the skin, 
the discomfort of the patient at the same time being much 
increased. 

Fig. 276. 







Half-ring modification of Thomas' splint for transport of fractures of the lower 

extremity. (Ashhurst.) 

Having applied a dressing to bring about fixation of the 
fragments, the patient should next be placed upon a broad 
board or settee; if a mattress cannot be obtained the frac- 
tured limb should be laid upon a mass of clothing, or upon 
straw, and he should be placed in a wagon or carried to the 
point where the subsequent treatment of the fracture is to be 
conducted. 

Fig. 277. 




Hinged Thomas' splint for transport of fractures. (Ashhurst.) 

Reduction or Setting of Fractures. — This should be effected 
as soon as possible after the occurrence of the injury and as 
soon as the surgeon is prepared to apply the dressings to keep 
the parts in their proper position; reduction at an early 
period is less painful to the patient, and is accomplished with 
more ease to the surgeon than at a later period, when marked 
inflammation and swelling are present at the seat of fracture. 
Reduction consists in bringing the fragments by manipula- 
tion, as nearly as possible in their normal position; this is 
accomplished by extension and manipulation with the hands, 
care being taken to use as little force as possible to attain 
the object. Very little force is required if the surgeon places 



DRESSING OF FRACTURES 447 

the part in such a position as to relax the muscles which pro- 
duce the displacement; when this is accomplished, the frag- 
ments can usually be pressed into position by the fingers 
without the application of considerable force. A roentgen- 
ray examination should be made after these manipula- 
tions to show satisfactorily that the reduction has been 
accomplished. When the reduction of a fracture has been 
accomplished the fragments are retained in position by the 
application of various splints or dressings which serve to 
prevent their displacement. 

Materials and Appliances Used in the Dressing of Fract- 
ures. — The Fracture Bed. — Many ingenious forms of beds 
have been devised for the use of patients suffering from 
fractures of the bones of the trunk and lower extremities, 
with the object of permitting the patient to have fecal 
evacuations without disturbing his position; but a simple 
bedstead provided with a firm hair mattress is usually more 
satisfactory than the complicated form of bed. 

It will be found more convenient in handling the patient 
to use a single bed not over 32 or 36 inches in width, and it is 
not essential that the mattress be perforated, as a bed-pan 
can usually be slipped under the patient. The use of an 
ordinary shallow tin pie-plate covered with a piece of old 
muslin to receive the fecal evacuations may be substituted for 
the bed-pan, and will be found in many cases more satis- 
factory, especially in the case of children suffering from 
fracture of the lower extremities. 

Splints. — After the reduction or setting of the fragments in 
cases of fracture, they are usually retained in position until 
union occurs by the use of splints held in position by means 
of bandages or strips of muslin. Splints may be made of 
wood, or of tin, lead, copper, or wire, binders' board, leather, 
felt, paper, gutta-percha or plaster of Paris. 

Wooden Splints. — The simplest splints are made from wood 
— white pine, willow or poplar being the best material to 
employ for their construction, being sufficiently strong to 
give fixation to the parts and at the same time being light. 
Splints made from smooth white pine, willow or poplar boards 
from i to J inch in thickness may be employed in the form of 



448 FRACTURES 

straight or angular splints, and their preparation is a matter 
of little difficulty. 

Wooden splints before being applied to the part should be 
well padded with cotton, oakum or hair; and where lateral 
wooden splints are employed in the treatment of fractures 
of the lower extremity it is usual to place bandages or junk 
bags between the limb and the splint. The carved wooden 
splints which are sold by the instrument makers are not to 
be recommended, as a rule, for unless the surgeon has a large 
number to select from, it is rare that a splint can be obtained 
to accurately fit any individual case. 

Binders' Board Splints. — Binders' board is an excellent 
material from which to construct splints; it is first soaked in 
boiling water, and when sufficiently soft is padded with cotton 
or a layer of lint and moulded to the part. It may be secured 
in position by a bandage; as it becomes dry, it hardens and 
retains the shape into which it was moulded. 

Undressed Leather Splint. — Undressed leather is a good 
material from which to construct splints; it is applied by 
first soaking the leather in boiling water, and after padding it 
with cotton or lint it is moulded to the part and retained in 
position by a bandage. 

Felt Splints. — These are made from wool saturated with 
gum shellac and pressed into sheets. This material is pre- 
pared for application to the surface by heating it before a fire 
until it becomes pliable or by dipping it into boiling water. 

Gutta-percha Splints. — These are made from sheets of this 
material from ^t to ^ inch in thickness, and may often be 
employed with advantage. The splint is prepared for use by 
immersing it in hot water; when it becomes soft it can be 
moulded to the surface. Care should be taken that it is not 
allowed to become too soft by long immersion, as it then 
cannot be conveniently handled. 

Paper Splints. — These are made from layers of Manila 
paper stiffened with starch and constitute a very fair substi- 
tute for some of the varieties of splints previously mentioned. 

Plaster of Paris, Starch, Chalk and Gum, Silicate of Potas- 
sium or Sodium Splints. — These may be employed for the 
construction of splints, either movable or immovable, in the 



DRESSING OF FRACTURES 449 

treatment of fractures; their methods of preparation and 
application are described on page 93 et seq. ; the plaster-of- 
Paris dressing is the one which is most generally used at the 
present time. 

Fracture Box. — This is a form of splint used in the treat- 
ment of fractures of the lower extremity, and consists of a 
board 18 to 20 inches in length, with a foot board firmly 
secured at its lower extremity; the sides are secured by hinges 
which allow them to be raised or lowered (Fig. 278) . A frac- 
ture box of greater length is required 
for the treatment of fractures about FlG - 278 - 

the knee-joint. jfjj| 

Bran, Sand or Junk Bags. — These IB 

are constructed by taking a piece 0^B±'±~=== — ' '-mill 
of unbleached muslin 5 feet in length < JIJiBliffiii:;,. ■ '■ 

and 14^ inches in width, doubling _, , ... ,, 

z . ip • Fracture box with movable 

it, and securing the free margins, sides. 

except at the mouth, by stitches so 

as to form a bag; the bag is then inverted so that the edges 
of the seams are brought on the inner surface of the bag. 
The bag is next filled with dry sand, bran, hair or straw and 
the mouth of the bag is closed by stitches or by being tied 
with a string. Bran bags with splints or sand bags are fre- 
quently employed in the treatment of fractures of the femur. 

Bandages. — These are made of muslin and are used to 
retain splints in the treatment of fractures and are also 
sometimes applied directly to the injured part before the 
application of splints to control muscular spasm and limit 
the amount of swelling; when a bandage is so used it is 
known as primary roller. The use of the primary roller is 
sometimes of the greatest service in the dressing of fractures, 
but its use in inexperienced hands has so often been followed 
by unfortunate results in the early treatment of fractures, or 
in cases which are not under constant observation, that I 
think it a safe rule of practice to discard entirely the use of 
the primary roller. 

Compresses. — These are made from a number of folds of 
lint, or of cotton or oakum, and are often employed to retain 
fragments in position or to make localized pressure upon cer- 
29 




450 FRACTURES 

tain points in the treatment of fractures. The compresses 
are held in position by strips of adhesive plaster, by a few 
turns of a roller bandage or by the splints. Compresses are 
sometimes employed to protect bony prominences of the 
skeleton from the pressure of the splints, but this purpose is 
often better effected by the use of small pieces of soap plaster 
spread on chamois skin fitted over the prominent points. 

Rack or Cradle. — This is made of wire or wooden hoops, 
and is often employed to support the weight of the bed- 
clothes in the treatment of fractures 
Fig. 279. f the lower extremity (Fig. 279) . 

Evaporating Lotions in Fracture.- — 
The employment of evaporating 
lotions such as lead-water and 
laudanum, or muriate of ammonium 
and laudanum or a solution of mag- 
Rack for supporting bed- nesium su i p h a te, to the skin in the 

clothes in fractures of the lower . r> r» • 

extremity. region of fractures is highly recom- 

mended by many surgeons, especially 
in fractures involving or situated near joints. They are here 
employed to relieve pain, to limit inflammatory swelling and 
to hasten absorption of the blood and serum at the seat of 
fracture. Many surgeons, on the other hand, think that 
their use causes irritation of the skin and delays the process 
of repair in the union of the fracture, and strongly condemn 
their employment. Personally, I have never seen bad results 
from their use, and have generally employed them in fractures 
near or involving the joints; but I do not consider their 
employment essential, and when I use them I do so for only 
two or three days. In cases of fractures accompanied with 
much pain and swelling, when the surgeon does not wish to 
use any of the lotions named, an ointment of ichthyol, 1 part, 
lanoline, 3 parts, spread on lint and wrapped around the 
limb, will often prove a satisfactory dressing, or a layer of 
cotton may be simply wrapped around the part before the 
application of the splints. 

Massage in the Treatment of Fracture. — Lucas-Champion- 
niere advocates and practises immediate and continuous 
massage in the treatment of fractures, and holds that by its 



OPERATIVE TREATMENT OF SIMPLE FRACTURES 451 

use pain is diminished, repair of the bone hastened by the 
profuse deposit of callus, and atrophy of muscles and stiffen- 
ing of joints avoided. 

Massage is employed as soon as possible after the fracture 
has occurred, and consists in manipulations with the thumb, 
the fingers, or the whole hand. The limb is held by an 
assistant and extension is made, or it is placed upon a firm 
pillow or a sand cushion. The manipulations should be 
made in the direction of the muscular fibers and of the blood 
current, and firm pressure should not be made directly over 
the seat of fracture. 

Massage should be practised for from fifteen to twenty 
minutes daily, and no retention apparatus should be applied 
in the intervals unless there is marked tendency to displace- 
ment of the fragments, when some form of retention appara- 
tus or splint may be used. These manipulations should be 
continued for some weeks, until union is firm at the seat of 
fracture. Massage has also been combined with the ambu- 
latory method of treatment of fractures of the lower extrem- 
ity. This method of treating fractures by massage may be 
said to be still on trial, sufficient experience not yet having 
accumulated to prove that it possesses marked advantage 
over the generally adopted method of treatment by immobil- 
ization. 

Operative Treatment of Simple Fractures. — Since the com- 
paratively safety of operations under strict aseptic precau- 
tions has been demonstrated, the operative treatment; of 
simple fracture attracted much attention. The advantages 
claimed by this method are accurate apposition of the frag- 
ments, and their fixation by plates, nails, screws or sutures, 
thus favoring prompt repair and diminishing the risk of non- 
union and deformity. 

There is no doubt that exposure of the fragments enables 
the surgeon to reduce the deformity and fix them accurately 
by means of mechanical appliances; but it should not be 
forgotten that the conversion of a simple fracture into a 
compound one entails a definite risk of infection in spite of 
the strictest precautions. At the present time the operative 
treatment of simple fractures is not employed as frequently 



452 FRACTURES 

as it formerly was. There are certain simple fractures where 
this method of treatment is to be most strongly recom- 
mended ; for instance, in those fractures where it is impossible 
to reduce the deformity by manipulation and in those in 
which the deformity persistently recurs after reduction, and 
in fractures where it is evident that the soft tissues are inter- 
posed between the fragments. 

In fractures of the patella the functional results of this 
method of treatment are so superior to those following the 
non-operative method that the former procedure is now gen- 
erally employed. 

The surgeon making use of this method of treatment of 
fractures should have in mind the value of perfect aseptic 
technic. 

SEPARATION OF THE EPIPHYSES. 

This lesion consists in a separation of the epiphysis of a 
bone from its diaphysis. The epiphyses are entirely cartilag- 
inous in infants, but ossification occurs later at various 
periods for different bones. The separation may occur at any 
time from birth up to the twenty-first year. The age at 
which traumatic separation of the epiphyses has been most 
observed is from the twelfth to the fifteenth year. Epiphy- 
seal separations may be simple or compound. 

Simple Separations. — Traumatic separations of the epiph- 
yses may result from direct and indirect violence, from trac- 
tion or torsion and in rare cases from muscular action. The 
injury is always accompanied by stripping of the periosteum 
from the end of the shaft of the bone, but it generally remains 
firmly attached to the epiphysis. Separation of the epiphyses 
in children results from the application of considerable force; 
according to Poland, an injury which would be able to pro- 
duce a dislocation in an adult will in a child usually result 
in a separation of an epiphysis. Separation of the epiphyses 
may result from disease, as in tuberculous and syphilitic 
ostitis and acute infective ostitis. Suppuration in the region 
of an epiphysis may result in its separation. 

Compound separations of the epiphyses are frequently met 
with, being most common at the lower epiphysis of the femur 



SEPARATION OF THE EPIPHYSES 453 

and the upper epiphysis of the humerus. These are grave 
injuries, from the fact that infection is apt to occur, resulting 
in suppurative osteomyelitis and necrosis, followed by arrest 
of growth of the limb and shortening. 

Symptoms. — These are mobility, deformity, crepitus, loss 
of function, pain and swelling. Mobility, which exists at a 
point where it should not be observed, is a most important 
symptom, and is most marked if the separation of the peri- 
osteum be extensive. Deformity is also more marked than 
in fractures, the smoothness of the separated surfaces permit- 
ting of displacement; this varies with the amount of dis- 
placement of the diaphysis and the amount and mode of 
application of the force. Crepitus is soft and muffled; loss 
of function is usually marked and pain and swelling at the seat 
of injury are soon followed by extravasation of blood. 

Diagnosis. — Separations without displacement are difficult 
to diagnose and are often considered as sprains of joints. In 
infants this lesion is difficult to recognize, and often escapes 
detection, but may be followed in a few weeks by swelling, 
suppuration and symptoms of chronic osteomyelitis. 

Separation of the epiphyses is most apt to be confounded 
with fracture or dislocation; the diagnosis is made from fract- 
ure by observing the line of separation, shape of the displaced 
epiphyseal fragment, the deformity (which is very character- 
istic in certain separations), and the soft character of the 
crepitus. From dislocation, the diagnosis is based upon the 
following signs: Dislocations are rare in infants and chil- 
dren. In separations of the epiphyses if the displacement is 
reduced it tends to recur upon removal of the force; while 
in dislocation if reduction is accomplished it is not likely to 
recur when the force is removed. Rigidity is present in 
dislocation, while preternatural mobility is marked in epi- 
physeal separation. In many joints the epiphysis will still be 
found to be connected with the joint and to retain its normal 
relations with the surrounding articular structures. In com- 
pound separations of the epiphyses the diagnosis may be 
made by observing that the displaced end of the bone is not 
covered by articular cartilage. A roentgen-ray examination 
is valuable in the diagnosis of this injury. 



454 FRACTURES 

Prognosis. — Union of the separated epiphyses occurs by the 
same process as that of a fracture. The amount of callus, 
which is formed largely by the periosteum uniting the frag- 
ments, varies with the completeness of their reduction. Non- 
union has never been observed in this injury. Anchylosis of 
the neighboring joint may result in spite of the greatest care 
in the reduction of the deformity and in the treatment, yet 
permanent deformity may be present and interfere very little 
with the function of the limb. Arrest of growth of the limb 
after this injury in young subjects may be observed, but is 
not a necessary result, for the epiphyseal cartilage may per- 
form its function as completely as before the injury, but is 
more apt to occur if the separation takes place between the 
epiphyses and the epiphyseal cartilage or the cartilage itself 
is severely injured. Arrest of growth is not marked in many 
cases, for the reason that the injury occurs at a period when 
the growth of the skeleton is almost complete. 

Treatment. — This consists in reduction of the deformity, 
which in many cases is difficult unless an anesthetic be admin- 
istered, and fixation of the parts after reduction by the use 
of splints and bandages, the dressings employed being similar 
to those used in fracture at a corresponding portion of the 
bone,. Muscular wasting should be prevented by the early 
employment of massage. Compound separations of the 
epiphyses are treated in the same manner as compound 
fractures, great care being taken to render the wound aseptic 
and to maintain it in this condition. The treatment of 
special epiphyseal separation is considered under fracture of 
these parts. 

DRESSING OF SPECIAL FRACTURES. 

Fracture of the Nasal Bone. — Fractures of the nasal bones 
are often accompanied with fractures involving the septum, 
the nasal process of the maxillary bone and the nasal spine of 
the frontal bone (Fig. 280). 

Treatment. — This consists in replacing the fragments, if 
displacement exists, by manipulation with the fingers over the 
seat of fracture and by pressure made from within the nostrils 



FRACTURES OF THE MALAR BONE 



455 



Fig. 280. 



by a probe or a steel director. When the displacement is 
once corrected it is not apt to recur, and in the majority of 
cases no dressing is required. Before resorting to any manip- 
ulation within the nasal cavities the mucous membrane should 
be thoroughly cocainized to render the operation painless. 
When there is a return of the depression of the fragments or 
displacement of the septum after correcting the deformity 
by raising the depressed fragment, or bending the septum 
into place with a director, the 
parts may be held in position 
by packing the nasal cavity 
firmly with a strip of antiseptic 
gauze or by the use of Asch's 
tubes. These are curved and 
perforated flattened vulcanized 
rubber tubes moulded to fit the 
nasal passages. 

In lateral displacements of 
the nasal bones from fracture, 
after reducing the displacement 
a small compress held over 
the fragment by strips of ad- 
hesive plaster will be the only 
dressing required. Narrow 
strips of gauze, fastened to the 
nose by collodion and drawn 
toward the cheek and fastened 
by collodion may be used to 
correct the deformity and hold 
the fragments in place. 

Profuse hemorrhage sometimes occurs after fracture of the 
nasal bones, and may require plugging of the nares to control 
it. Fractures of the nasal bones are usually quite firmly 
united in two weeks and dressings may be dispensed with 
after this time. 

Fractures of the Malar Bone and Zygoma. — These fractures 
are usually the result of direct force; the displacement is 
upward or backward, and when the zygomatic arch is broken 
the fragments from pressure upon the masseter muscle or on 




Fracture of nasal bones, eighteen hours 
after injury. (Ashhurst.) 



456 



FRACTURES 



Fig. 281. 



the tendon of the temporal muscle may interfere with the 
movements of the lower jaw in mastication (Fig. 281). This 
displacement is corrected by cutting down upon the fragment 
and elevating it or by passing a tenaculum into the fragment 
and raising it. Outward displacements may be corrected by 
pressure and the application of a compress. 

Treatment. — The dressing of these fractures after the cor- 
rection of the deformity consists in the application of a com- 
press of lint over the seat of fracture, held in position by 
strips of adhesive plaster or a bandage. There is little 

tendency to recurrence of the de- 
formity after it has been corrected, 
and union at the seat of fracture 
is usually firm at the end of three 
weeks. 

Fractures of the Upper Jaw. — 
These fractures may involve the 
body, the nasal processes or the 
alveolar processes. 

Treatment. — The deformity 
should be corrected, and if any 
teeth have been displaced they 
should be replaced; if there is com- 
minution of the alveolus the teeth 
in the separate fragments may be 
fastened together by fine wire to 
fix the fragments and hold them 
in place; the teeth of the lower 
jaw should be brought up in con- 
tact with those of the upper jaw, and the jaws should be 
secured together by the application of a Gibson or a Barton 
bandage (Figs. 282 and 283). Interdental splints, made of 
silver or aluminum with grooves to fit the teeth, or of gutta- 
percha, are also employed in the dressing of these fractures. 
The patient should not be allowed to move the jaw in mas- 
tication, and should be nourished by liquid and semisolid 
food, which may be taken without removing any teeth to give 
space for its introduction. The bandage should be removed 
every second or third day, and it should be reapplied in the 




Fracture of right malar bone. 
(Ashhurst.) 



FRACTURES OF THE LOWER JAW 



457 



same manner. Union is usually firm at the end of four or 
five weeks, and dressings may be dispensed with at this time. 
Fractures of the Lower Jaw. — Fractures of the lower jaw 
may involve the body, ramus, the condyle or the coronoid 
process, the most usual seat of fracture being near the mental 
foramen; it is often broken at two places at once; if these 
fractures be one on each side of the symphysis, the tongue 
may fall back and interfere with the patient's respiration. 
These fractures are in many cases rendered compound by 
laceration of the mucous membrane, or the injury may con- 
sist in a separation of a portion of the alveolar process of the 
bone. 

Fig. 282. Fig. 283. 





Dressing for fracture of the upper jaw. 



Dressing for fracture of the lower jaw. 



Fracture through the neck of the condyle is a serious 
injury which leads to anchylosis. The external pterygoid 
muscle rotates the condyloid fragment forward. Fracture 
of the coronoid process is a very rare accident and difficult to 
detect except by roentgen-ray examination. 

Treatment. — The dressing of a fracture of the lower jaw, 
after reducing the displacement and replacing any loosened 
or detached teeth, consists in applying a pad of lint under 
the chin and bringing the jaw up against the upper jaw, hold- 
ing the compress in place and securing the jaws firmly in 



458 FRACTURES 

contact by applying a Barton (Fig. 283), a modified Barton 
or a Gibson bandage. The bandage should be removed and 
reapplied at the end of the second or third day, and at like 
intervals during the course of treatment. The patient should 
be fed upon a liquid or semisolid diet, not being allowed to 
chew solid food until union at the seat of fracture has become 
firm. A very satisfactory temporary dressing for a fracture 
of the lower jaw consists in the application of a four-tailed 
sling. 

Some surgeons prefer to use an external splint moulded 
from pasteboard or gutta-percha fitted to the chin in the 
dressing of this fracture (Figs. 284 and 285), this being padded 
with cotton and held in place by a Barton or Gibson bandage. 

Fig. 284. Fig. 285. 




Shape of splint before being fitted to chin. Splint moulded to fit chin. 

(Roberts.) (Roberts.) 

Where there is much difficulty in keeping the fragments in 
position wiring together of the teeth may be employed, or 
the fragments may be perforated with a drill and held in 
place by a strong silver wire suture. In double fractures on 
each side of the symphysis if the tongue falls back the frag- 
ments should be fixed by wiring. In fracture of the condyle, 
as it is difficult to correct the deformity by manipulation, 
operation is indicated. Interdental splints of metal or gutta- 
percha are also sometimes used for this purpose. The best 
results in fractures of the jaw with marked displacement are 
obtained by the use of interdental splints; a plaster cast of 
the teeth is first made and from this is constructed a gold, 
silver or aluminum splint, which fits the teeth accurately. 
The splint may be cemented to the teeth in one jaw or may 



FRACTURES OF THE LARYNX OR TRACHEA 459 

be worn between the jaws, being held in position by holding 
the jaws together by a Barton bandage. During the course 
of treatment of fracture of the jaws the mouth often becomes 
very offensive from fermentation of the saliva and discharges, 
and it is well to use frequently a mouth wash of chlorate of 
potassium and tincture of myrrh or boric acid solution. 

The dressings for fracture of the lower jaw are applied for 
four or six weeks, the union usually being quite firm at the 
end of this time. 

Fracture of the Hyoid Bone. — In fracture of the hyoid 
bone if displacement exists its reduction is facilitated by 
pressure made with the finger in the pharynx. 

Treatment. — This consists in enforced quiet and the use of 
opium if cough is a prominent symptom, and the inflamma- 
tory symptoms may require the employment of active local 
treatment. A dressing may sometimes be employed with 
advantage, consisting of a splint of pasteboard or leather 
moulded to the anterior portion of the neck. 

Fractures of the Larynx or Trachea. — In fractures of the 
larynx or trachea where there is little displacement and 
dyspnea is not marked, the parts should be supported by 
the application of compresses of lint held in place by strips 
of adhesive plaster. In fractures of larynx the thyroid 
cartilage is the one most frequently involved, and serious 
asphyxia may develop from edema of the glottis. If, on the 
other hand, the respiration is embarrassed or there is free 
expectoration of blood, tracheotomy should be performed, 
and if the injury be seated in the larynx the displacement of 
the fragments may be overcome by manipulation with the 
finger or a director through the tracheal wound, or the larynx 
may be packed with a strip of antiseptic gauze to control 
hemorrhage or hold the fragments in position, the patient 
in the meantime breathing through a tracheotomy tube 
secured in the tracheal wound; the packing should be 
removed in a few days, the tracheotomy tube being perman- 
ently removed as soon as the patient can breathe comfortably 
through the larynx with the tracheal wound closed. In 
fracture of the trachea the opening into the trachea should 
be below or at the seat of injury. 



460 



FRACTURES 



Fig. 286. 



Fractures of the Ribs.— Fractures of the ribs are more 
frequent than fractures of any other bones of the trunk; this 
injury is extremely rare in children and most common in male 
adults; the ribs most commonly broken are those from the 
fourth to the tenth; the most common seat of fracture is near 
the anterior or posterior portion; the displacement is usually 
not marked unless a number of ribs be broken, being pre- 
vented by the intercostal muscles and aponeuroses. The 
marked symptoms are pain on forced inspiration and upon 
sudden motion, localized tenderness and sometimes distinct 
mobility and crepitus; this can often be detected by the use 
of a stethoscope. Visceral injuries are not usual, but may 

be serious; subcutaneous emphysema, 
from rupture or puncture of the lung, 
hemothorax and traumatic pneumonia. 
Treatment.— The dressing of frac- 
tures of the ribs is best accomplished 
by enveloping the side of the chest 
on which the rib or ribs are broken 
with broad straps of adhesive or rub- 
ber plaster. The adhesive straps 
should be 2\ inches in width and suf- 
ficiently long to extend from the 
spine to the middle of the sternum. 
The straps are warmed and the first 
strap is firmly applied at the base 
of the chest, extending from the spine to the midsternal line; 
a number of ascending straps are applied in this way, each 
strap overlapping the preceding one by about one-third of 
its width until half the chest is covered in (Fig. 286). This 
dressing usually gives the patient much comfort, and the 
straps need not be renewed until they become slightly 
loosened, usually at the end of a week or ten days; they 
should then be renewed in the same manner. The dressings 
are usually dispensed with at the end of three or four weeks, 
as repair of the fracture is generally well advanced at this 
time. 

A satisfactory temporary dressing consists in surrounding 
the chest by a broad binder of stout linen or muslin; indeed, 




Adhesive plaster dressing for 
fracture of the ribs. 



FRACTURES OF THE STERNUM 



461 



Fig. 287. 



some surgeons prefer to employ this dressing during the 
course of treatment but, as a rule, I think it is not as good a 
dressing as the adhesive plaster dressing, as the former con- 
fines the movements of both sides of the chest. 

Fractures of the Costal Cartilages. — These fractures often 
take place at the junction of the cartilages with the ribs 
or in the body of the cartilages, and the union of the fracture 
usually takes place by the production of a mass of bone at 
the seat of fracture. 

Treatment. — It consists in the application of strips of 
adhesive plaster applied in the same manner as for fracture 
of the ribs and the dressings 
should be retained for about 
the same time. 

Fractures of the Sternum. — 
Fractures of the sternum are 
rare injuries, but diastasis of 
the bones of the sternum is a 
more common accident. This 
injury usually results from 
crushing force; inward dis- 
placement of the fragments 
may produce visceral injury as 
evidenced by hemoptysis, dys- 
pnea, cyanosis and subcuta- 
neous emphysema. Fracture 

of the ensiform process with backward displacement may 
cause gastric symptoms. 

If inward displacement of the fragment is marked, its 
reduction can sometimes be accomplished by making hyper- 
extension over a small pillow and drawing the arms backward. 

Treatment. — The treatment for both fracture and diastasis 
is the same and consists in the application of a compress over 
the seat of fracture held in place by a broad bandage, or, 
better, by strips of adhesive plaster (Fig. 287) applied so as 
to cover and fix the anterior portion of the chest, covering 
the entire length of the sternum. This dressing should be 
retained for at least four weeks, being renewed if it becomes 
loose at the end of a week or ten days. 




Adhesive plaster dressing for fracture 
of the sternum. 



462 FRACTURES 

Fractures of the Pelvis. — These fractures are usually caused 
by direct violence and may involve the ilium, ischium, pubis 
or sacrum. Vertical fractures, either single or double, may 
occur; the latter break the pelvic ring and are not uncom- 
mon. Separations of the pelvic bones from their junctions 
may also occur as well as fracture of the rim of the ace- 
tabulum from force transmitted through the femur, and are 
often serious injuries from implication of the pelvic viscera. 
Visceral injuries from fracture of the pelvic bones occur in 
about one-sixth of these cases, and have a mortality of 30 
per cent. 

Treatment. — The reduction of the displacement should be 
first accomplished as far as possible by external manipulation, 
together with internal manipulation by the fingers introduced 
into the rectum, or into the vagina in the female. The 
patient should be placed upon a firm bed on his back, with 
the knees slightly flexed over a pillow, and the parts should 
be kept at rest by surrounding the pelvis with broad straps 
of adhesive plaster or a stout muslin binder, or by a firmly 
applied padded pelvic belt. The hip-joints should be kept 
at rest by the application of pasteboard splints or by sand 
bags. Fractures and diastases of the pelvic bones may also 
be satisfactorily treated by the application of a plaster-of- 
Paris dressing. The parts being well padded with cotton, a 
plaster dressing is applied to include the upper portion of both 
thighs, the pelvis and a portion of the trunk. The dressings 
should be retained for a period of at least six weeks. 

When these fractures are complicated by injury of the 
pelvic viscera various operative procedures may be required, 
which will compel the surgeon to modify the method of dress- 
ing. 

Fractures of the Sacrum and Coccyx. — The dressing of 
fractures of the sacrum, after effecting reduction of the frag- 
ments as far as possible by pressure from within the rectum, 
consists in the application of broad adhesive straps around the 
pelvis, the patient at the same time being kept at rest in bed. 

When the coccyx is fractured, after reduction of the dis- 
placement, which may sometimes be accomplished by mani- 
pulation with the finger in the rectum, the patient should 



FRACTURES OF THE VERTEBRA 463 

be confined to bed and the bowels kept at rest by the use of 
opium by suppository. The patient should remain in bed 
for two or three weeks. 

Fractures of the Vertebrae. — Fractures of the vertebrae are 
always most serious injuries, not only from the damage to 
the bones themselves, but also from that to the spinal cord, 
membranes and nerves which often accompanies them. 
These injuries are often associated with dislocations of the 
vertebra?, so that the term fracture-dislocation is used to 
describe them. This combined lesion occurs in 60 per cent 
of cases of injury of the spinal column, while isolated frac- 
tures and dislocations form each about 20 per cent of these 
injuries. In transporting or turning in bed a patient suffer- 
ing from fracture of the vertebrae great care should be 
exercised, for rough or sudden motions may cause a displace- 
ment of the fragments which might, by injury of, or pressure 
upon, the spinal cord, rapidly prove fatal. The prognosis 
is always bad in vertebrae fractures; as a rule, the higher the 
injury the graver is the prognosis. Recovery without loss 
of function may follow fractures of the lower lumbar vertebrae. 

Treatment. — If the deformity is marked, effort should be 
made to reduce it by extension and counter-extension; and 
the result may be successful, especially if the fracture be 
associated with a dislocation of the vertebrae. In some cases 
the use of permanent extension by means of weights attached 
to the legs, shoulders and chest by adhesive plaster and 
bandages has been successful in reducing the deformity. 
Laminectomy may be practised in certain cases — where it is 
probable that pressure symptoms are due to some extra- 
medullary lesion, displaced bone or blood clot. 

The patient should be placed upon his back upon a bed 
with a hair mattress, or better, if it can be obtained, a water 
bed, which consists of a rubber mattress filled with water 
which distributes the weight of the patient's body evenly 
over the surface. Whatever form of bed be used, the greatest 
care should be exercised to keep the patient absolutely clean, 
and the parts of the body or limbs which are exposed to pres- 
sure should be frequently bathed with alcohol or soap lini- 
ment; and to distribute the pressure small pads should be 



464 FRACTURES 

placed under the parts and changed at intervals. These 
precautions are necessary to prevent, if possible, the forma- 
tion of extensive bed sores, which are a frequent and trouble- 
some complication of these injuries. 

The boivels should be carefully watched, and, if constipa- 
tion is present it should be relieved by the use of enemata; 
and, as it is not desirable to lift the patient to slip a bed pan 
under him the discharges may be received in a flat tin plate 
pushed under the thighs and buttocks or on pads of oakum 
or old muslin. 

The care of the bladder is also a matter of the greatest 
importance; the retention which at first exists should be 
relieved by the use of a flexible catheter carefully sterilized 
and introduced with great gentleness, and when incontinence 
supervenes a catheter which has been thoroughly sterilized 
should also be used at intervals; the employment of a soft 
instrument, if used with care, is not apt to produce injury 
to the urethra or bladder. 

The employment of a plaster-of-Paris jacket has been 
followed in some cases by good results, and it may be applied 
early in the case or after the patient has been kept in the 
recumbent posture for some weeks; by its use it is often 
possible to get the patient out of bed and allow him to sit 
in a chair. 

In fractures involving the cervical vertebra care should be 
exercised in lifting or moving the head; it is often of advan- 
tage in these cases to apply short sand bags to the sides of 
the neck and head, to give additional fixation to the parts 
while the patient is in the recumbent posture, or, if he is 
allowed to get out of bed, to apply a moulded leather or 
pasteboard splint to the neck, shoulders and back of the 
head for the same purpose. 

The course of treatment in cases of fractures of the ver- 
tebrae, if the patient does not succumb to the injury in a few 
days or weeks, often extends over many months, and recovery 
is often more or less incomplete as regards the function of the 
parts below the seat of fracture. 

Fractures of the Skull. — The injuries may result from the 
application to the skull of a bending, bursting or explosive 



FRACTURES OF THE CLAVICLE 465 

force; they may be simple, compound, depressed or punctured. 
The fracture may involve eitheT the vault or base or both. 
Fractures of the skull are most serious injuries when accom- 
panied by intracranial complications. 

Treatment. — This depends largely upon the nature of the 
injury — whether simple or compound — and the condition of 
the cranial contents. In simple fractures unaccompanied 
with cerebral symptoms no special dressing is required, but 
in compound fractures where loose fragments are present 
these should be removed; and if there is no depression of the 
fragments, and if no cerebral symptoms are present, the 
wound should be drained, carefully closed and dressed anti- 
septically, the dressings being held in place by a recurrent 
bandage of the head. The patient should be put to bed, 
and the use of an ice cap to the head is often of service. The 
diet should be restricted, while calomel and opium or bromide 
of potassium should be administered, or urotropine which 
has the property of rendering the cerebrospinal fluid bacteri- 
cidal. It is well to keep the patient for a few weeks in a 
quiet and darkened room. Where cerebral symptoms are 
present, either in simple or compound fractures, and trephin- 
ing is resorted to, the dressing of the wound is similar, and 
the same general treatment should be adopted. In all cases 
of fracture of the skull, whether subjected to operative treat- 
ment or not, it is well to keep the patient at rest in bed for 
three or four weeks, and he should be cautioned to avoid 
excesses afterward and should not resume active work for 
some months. 

Fractures of the Clavicle. — Fractures of the clavicle may 
very frequent both in children and adults and may be com- 
plete or incomplete; in the former the deformity is marked 
while in the latter variety of injury, the deformity is not 
usually very marked (Fig. 288). The indications for treat- 
ment in complete fractures of the clavicle are to relax the 
sternocleidomastoid muscle, to prevent the weight of the 
arm on the injured side from dragging down the outer frag- 
ment of the clavicle and by fixing the scapula, to carry the 
attached external fragment outward and backward. A large 
variety of dressings have been devised and used to accomplish 
these objects. 
30 



466 



FRACTURES 



Dressing by Position. — The treatment of fractures of the 
clavicle by position is accomplished by placing the patient 
in bed on his back upon a firm mattress with a low pillow 
under his head, and the arm on the side of injury should be 
fastened to the side of the chest by a few circular turns of a 
bandage passing around the arm and chest; the deformity 
is usually very satisfactorily reduced upon the patient assum- 
ing this position, and after three weeks' rest in this position 
the union is generally sufficiently firm to allow the patient 
to get out of bed and be about with the arm bound to the side 

Fig. 288. 




Deformity in fracture of left clavicle. (Ashhurst.) 



or carried in a sling or with a Velpeau bandage applied, 
without any recurrence of the deformity. 

Temporary Dressing. — A satisfactory temporary dressing for 
fractures of the clavicle consists in the application of a four- 
tailed bandage; the bandage is made from a piece of muslin 
2 yards in length and 14 inches in width; a hole is cut in its 
center about 4 inches from its margin, to receive the point 
of the elbow; the bandage is then split into four tails in the 
line of the hole and to within 6 inches of it; the body of the 
bandage should be applied so that the point of the elbow 



FRACTURES OF THE CLAVICLE 



467 



rests in the hole, and a folded towel being placed in the axilla, 
the lower tails should be carried, one anteriorly, the other 
posteriorly, diagonally across the chest and back, to the neck 
on the side opposite the seat of fracture and secured; the 
remaining tails are next carried around the lower part of the 
chest and secured so as to fix the arm to the side of the body 
(Fig. 289). 

In some cases the deformity is corrected by the application 
of a posterior figure-of-eight bandage, the forearm on the 
side of injury being carried in a sling (Fig. 290). 



Fig. 289. 



Fig. 290. 




Four-tailed bandage for fracture of 
the clavicle. 



Posterior figure-of-eight dressing for fracture 
of the clavicle. 



Sayre's Dressing. — This consists of two strips of adhesive 
plaster 3 J inches wide and 2 yards in length. The first strip 
is looped around the arm just below the axillary margin, and 
is pinned or sewed with the loop sufficiently open not to 
constrict the arm. The arm is then drawn downward and 
backward until the clavicular portion of the pectoralis major 
muscle is put sufficiently upon the stretch to overcome the 
action of the sternocleidomastoid muscles, and in this way 
draws the sternal fragment of the clavicle down to its place. 



468 



FRACTURES 



The strip of plaster is then carried completely around the 
body and pinned or stitched to itself on the back (Fig. 291). 
The second strip is next applied, commencing upon the front 
of the shoulder of the sound side; thence it is carried over 
the top of the shoulder diagonally across the back, under the 
elbow, diagonally across the front of the chest to the point 
of starting where it is secured by pinning or sewing. A slit 
is made in this strip to receive the point of the elbow. Before 



Fig. 291. 



Fig. 292. 





Sayre's dressing for fracture of the 
clavicle. First strip applied. 



Sayre's dressing for fracture of the 
clavicle. Second strip applied. 



the elbow is secured by the plaster it should be pressed well 
forward and inward (Fig. 292). 

Velpeau's Dressing. — This may also be used in the treatment 
of fractures of the clavicle (Fig. 293) . A compress may also 
be secured by the vertical turns of this bandage over the 
seat of fracture if needed. The application of the bandage is 
described on page 66. 

In any form of dressing in which the arm is held against 



FRACTURES OF THE CLAVICLE 



469 




the side of the chest it is well to apply a folded towel or piece 
of lint between the arm and chest to prevent the skin surfaces 
from becoming excoriated. 

Modified Velpeau's Dressing. — A modified form of Velpeau's 
dressing for fracture of the clavicle is applied as follows: A 
soft towel or piece of lint is placed against the side of the body 
and over the front of the chest, and held in position by a 
strip of adhesive plaster; the 
arm is next placed in the 
Velpeau position, a good- 
sized pad of lint is next ap- 
plied over the scapula and 
this is held in place by a 
strip of adhesive plaster 2\ 
inches in width and 1^ yards 
in length; this strip is con- 
tinued downward and for- 
ward so as to pass over the 
point of the elbow and is 
carried diagonally across the 
chest to the shoulder of the 
opposite side and is secured, 
a slit being cut in it to re- 
ceive the point of the elbow ; 
a compress of lint is next 
placed over the seat of frac- 
ture and held in place by a 
strip of adhesive plaster; an 
additional strip of plaster is 
next carried from the spine 
around the arm and chest 

and secured on the opposite side of the chest; circular turns of 
a roller bandage are then passed around the chest, including 
the arm from below upward until the arm is securely fixed to 
the body, and the dressing is finished by making one or two 
turns of the third roller of Desault (Fig. 294) . Or the turns 
of the third roller of Desault may be applied first and the 
dressing may be finished by circular turns of a roller passing 
around the arm and chest, extending from the elbow to the 
shoulder. 




Velpeau's dressing for fracture of the 
clavicle. 



470 FRACTURES 

The removal of dressings and their reapplication will 
depend upon the comfort of the patient and the manner in 
which they keep their position. As a rule, in fractures of 
the clavicle the dressings are removed at the end of the 
second or third day, the parts are inspected and the skin is 
sponged with dilute alcohol; the dressings are then reapplied, 
and if the patient is comfortable and the parts are in good 
position the dressings are made at less frequent intervals 
until union is completed at the seat of fracture. 

Fig. 294. 




Modified Velpeau dressing for fracture of the right clavicle. 

Union in cases of fracture of the clavicle is generally quite 
firm at the end of four or five weeks, and at this time the 
dressings may be removed, and the patient should carry 
the arm of the affected side in a sling for several weeks, and 
should not undertake any work requiring forcible movements 
of the arm until eight or ten weeks have elapsed from the 
receipt of the injury. 

Fractures of the Clavicle in Children. — In the treatment 
of fractures of the clavicle in children the Velpeau or modified 
Velpeau dressing will be found to be the most satisfactory 
dressing to employ; and as these patients are particularly 



FRACTURES OF THE SCAPULA 471 

apt to disarrange the dressings, it is well to render them 
additionally secure by applying a few broad strips of 
adhesive plaster over the turns of the roller bandage, the 
strips following the turns of the bandage. 

The time reqtiired for union in fractures of the clavicle in 
children is somewhat shorter than in adults; the dressings 
may be removed at the end of three weeks. 

Fractures of the Scapula.— Fractures of the scapula usually 
occur from direct violence and may involve the body, neck, 
acromion or coracoid process of the bone. Fractures of this 
bone are rare, those of the acromion process being most 
common. As an exact diagnosis of these injuries is often 
difficult a roentgen-ray examination should be made. 

Fracture of the Body of the Scapula. — Treatment.— If deform- 
ity is present it is reduced by manipulation and compresses of 
lint are placed above and below the seat of fracture and held 
in place by adhesive strips; the arm is next fixed to the side 
of the body by spiral turns of a roller bandage passing around 
the arm and chest and the forearm is supported in a sling. 

Fracture of the Neck, Acromion or Coracoid Process of the 
Scapula. — In fracture of the surgical neck of the scapula the 
line of fracture passes through the suprascapular notch, 
detaching both the coracoid and glenoid processes. Fracture 
of the acromion process is the most common fracture met 
with in this bone and may be compared with separation of 
the epiphysis; that of the coracoid process is very rare and 
is generally produced by muscular action. 

Treatment. — The treatment of these fractures consists in 
reducing the displacement by manipulation and placing a pad 
of lint or a folded towel in the axilla and binding the arm to 
the body by spiral turns of a roller bandage passing around 
the arm and chest and supporting the forearm in a sling. 
These fractures may also be dressed by first placing a pad 
of lint or a folded towel in the axilla and then securing the 
arm in the Velpeau position by the application of a Velpeau 
bandage (Fig. 293). Fractures of the scapula may also be 
treated by the application of a plaster-of-Paris bandage, the 
deformity being reduced, the arm is placed against the chest, 
a fold of lint being interposed; a flannel bandage is next 



472 



FRACTURES 



Fig. 295. 



carried over the shoulder and around the chest and arm, and 
this dressing is covered by the turns of a plaster-of-Paris 
bandage (Fig. 295) h In fractures of the acromion or coracoid 
processes the union is usually fibrous. In the treatment of 
fractures of the scapula the dressing should be retained for 
about four weeks. 

Fractures of the anatomical neck are rare and may be 
largely intra-articular. The semiglobular fragment is dis- 
placed toward the axilla and may 
tear the capsule and escape into 
the axilla. 

Fractures of the Humerus. — 
Fractures of the humerus may 
involve the upper extremity, the 
shaft or the lower extremity of the 
bone. 

Fractures of the Upper Extremity 
of the Humerus. — These include 
fractures of the head and anatom- 
ical neck of the bone. Fractures 
may separate the tuberosities, the 
greater tuberosity being the one 
usually involved, resulting from 
muscular action and rarely from di- 
jj| ^k "*"«*^^J rec ^ violence, or they may involve 

~~ the surgical neck of the humerus; 

and, finally, separation of the 
upper epiphysis of the humerus; 
this is a very frequent fracture. 
Treatment. — The most satisfactory dressing for all fractures 
of the humerus above the upper third of the bone is applied 
as follows: A primary roller should be evenly applied from 
the tips of the fingers to the seat of the fracture, the arm 
being flexed at the elbow before the bandage is carried above 
this point, to prevent the dangerous constriction which might 
result if the bandage were applied with the arm in the straight 
position, and it were afterward flexed at the elbow. A folded 
towel or a thin pad of lint should next be placed in the axilla 
and over the outer surface of the chest to furnish a firm basis 




Plaster-of-Paris dressing for frac- 
ture of the scapula. 



FRACTURES OF THE HUMERUS 



473 



Fig. 296. 



of support for the humerus, and also to prevent excoriation 

from the contact of the skin surfaces. A splint of pasteboard, 

felt or leather (Fig. 296) is next moulded to 

the shoulder and arm; this should be long 

enough to extend some distance below the 

seat of fracture and wide enough to cover 

in about one-half of the circumference of 

the arm, and is padded with cotton and 

fitted to the shoulder and arm. The splint 

and arm are next secured to the side of the 

body by spiral turns of a roller bandage, 

including the arm and chest in its turns 

and applied from the elbow to the top of 

the shoulder. The forearm is carried in a 

narrow sling suspended from the neck (Fig. 

297) . This dressing should be removed at 

the end of twenty-four or forty-eight hours, 

and after the parts have been inspected 

and sponged with alcohol the dressings should be reapplied 

in the same manner, and if the patient is comfortable they 

need not be disturbed again for three or four days, subse- 




Moulded splint for 
shoulder and arm. 



Fig. 297. 




Dressing for fracture of the upper extremity of the humerus. 



474 



FRACTURES 



Fig. 298. 



quent dressings being made at the same intervals. Union in 
fractures of the upper extremity of the humerus, except in 
those within the capsule, in which bony union is the excep- 
tion, is usually quite firm at the end of five or six weeks, and 
the dressings can be dispensed with at this time. 

Separation of the Upper Epiphysis of the Humerus. — This 
accident is not uncommon in patients under twenty years of 
age, and may be confused with fracture of the neck of the 

humerus. The displacement is 
due to muscular action; the dia- 
physis can be felt under the 
anterior fibers of the deltoid. 
There is usually a marked pro- 
jection of the upper extremity 
of the lower fragment in front 
of the shoulder (Fig. 298). 

Treatment. — This consists in 
reducing the displacement by 
manipulation and the dressing 
is similar to that employed in 
fracture of the neck of the hum- 
erus (Fig. 297) . In some cases, 
after the deformity has been 
reduced under anesthesia, the 
reduction is maintained by fixing 
the arm in the abducted position 
by a plaster-of-Paris bandage for 
a few weeks. The functional 
result following this injury is 
usually very good. 
Fracture of the Shaft of the Humerus. — This fracture may 
occur at any point between the surgical neck and the condyles 
of the humerus; the line of fracture is usually oblique. In 
fractures of the shaft above the insertion of the deltoid the 
lower fragment is carried upward and outward by action of 
this muscle, while the upper fragment is pulled inward by 
the axillary muscles. In fractures below the insertion of the 
deltoid the displacement is reversed. 




Separation of upper epiphysis of the 
humerus. 



FRACTURES OF THE HUMERUS ' 



475 



Treatment. — This consists in the application of a primary 
roller from the tips of the fingers to the seat of fracture; a 
short, well-padded, wooden splint extending from the axilla 
to a point a little above the internal condyle is next placed 
on the inner surface of the arm and against the chest; a 
moulded pasteboard or felt splint, fitted to the shoulder and 
outer side of the arm and extending a short distance below 
the seat of fracture, is padded with cotton and applied to the 
shoulder and arm. The splints are held in position by the 
turns of a bandage and the arm is secured to the body by 
spiral turns of a roller bandage carried around the chest and 
arm, and the forearm is carried in a sling suspended from the 
neck. The dressing is much the same as that for fracture of 
the upper part of the humerus, with the addition of the short 
internal splint. 

Fig. 299. 




Internal angular splints. 



This fracture may also be treated by the use of three 
narrow coaptation splints of wood or binders' board, extend- 
ing from the axilla to a point just above the elbow, being well 
padded these are placed one anteriorly, one posteriorly and 
one externally. These are held in position by a bandage; 
a shoulder cap is next applied and the arm is firmly bound to 
the side of the chest by circular turns of a bandage. 

Fracture of the shaft of the humerus may also be dressed 
by first applying a primary roller and then placing the fore- 
arm and arm upon a well-padded internal angular splint 
(Fig. 299) . Care should be taken to see that the end of the 



476 FRACTURES 

splint extends only to the axilla and does not press upon the 
brachial vein. A pasteboard or felt moulded splint is next 
applied to the shoulder and outer side of the arm, and should 
be long enough to extend below the seat of fracture. The 
splints are held in position by turns of a roller bandage begin- 
ning at the fingers and carried up to the shoulder, and finished 
with a few spica-of-the-shoulder turns (Fig. 300). If there 
is great overlapping of the fragments producing marked 
shortening the patient should be kept in bed and the elbow 
flexed and weight or elastic extension made by adhesive strips 

Fig. 300. 




Dressing for fracture of the shaft of the humerus with internal angular splint and 
external splint of binders' board. 

applied to the arm, short coaptation splints also being applied. 
If the patient is treated as a walking case the same result can 
be accomplished with a bag of shot or weight fastened to the 
arm so as to hang below the elbow. The arm is supported by 
a sling applied at the wrist and sometimes for additional 
security the arm is bound to the side of the body by spiral 
turns of a bandage carried around the arm and chest. The 
after-treatment of these fractures as regards the removal and 
renewal of the dressings is the same as in cases of fracture of 
the upper portion of the humerus; the dressings should be 
retained for iive or six weeks. 



FRACTURES OF THE HUMERUS 



477 



Extension, with adhesive straps and a weight, with the 
use of a Thomas arm splint (Fig. 301) is often employed with 
advantage where the shortening and deformity are marked, 
and it is found impossible to keep the fragments in good 
position with the ordinary dressing. The use of this method 
requires the patient to be in bed on his back. 

Fig. 301. 




Thomas' arm splint. (Ashhurst.) 



Fig. 302. 



Fractures of the Lower Extremity of the Humerus. — These 
include fractures at the base of the condyles, splitting fracture 
between the condyles or those of the internal or external con- 
dyle and epiphyseal separation of the lower epiphys s of the 
humerus 

Treatment. — The displacement is reduced by extension and 
manipulation, and before applying any splint it is well in 
many cases to apply over the 
region of the fracture several 
layers of cotton wadding. An 
anterior angular splint (Fig. 
302) well padded with cotton 
or oakum is next applied and 
held in position by the turns 
of a roller bandage applied from 
the fingers to the upper por- 
tion of the splint (Fig. 303). 
Great care should be taken 

to see that the angular edge of the [splint does not press 
too firmly upon the tissues in the bend of the elbow, as 
sloughing of the skin and damage to the nerves has resulted 
from neglect of this precaution. These fractures may also be 
dressed with a well-padded internal angular splint, this splint 
being substituted by an anterior angular splint at the end 
of ten days or two weeks. 




Anterior angular splint. 



478 



FRACTURES 



Some surgeons prefer to dress fractures of the condyles of 
the humerus with the arm in the extended position upon a 



Fig. 303. 




Dressing for fracture of the lower extremity of the humerus with anterior angular splint. 

Fig. 304. 




Gunstock deformity after fracture of the condyle of the humerus. 

straight anterior splint, or with short, narrow pasteboard 
splints applied around the joint, as favoring more accurate 
coaptation of the fragments, and diminishing the tendency 



FRACTURES OF THE HUMERUS 



479 



to what is known as gunstock deformity and loss of the carry- 
ing angle (Figs. 304 and 305) . If this position is employed a 
straight wooden splint is applied to the anterior surface of 
the arm and forearm, or moulded splints of pasteboard may 
be used, and after the union is moderately firm, at the end 
of two weeks the elbow should be flexed and kept in this posi- 
tion during the remaining time of the treatment. 

Treatment by Acute Flexion 
{Jones 1 Method). — In this Fig. 305. 

dressing of fractures of the 
condyles of the humerus the 
displacement of the fragments 
is corrected by manipulation 
and the forearm is placed in a 
position of acute flexion at the 
elbow (Figs. 306 and 307), 
and the hand of the injured 
arm is brought up and is 
supported by a sling carried 
around the neck (Fig. 308). 
The flexion of the forearm 
on the arm may also be ren- 
dered more secure by passing 
broad strips of adhesive plas- 
ter or bandage around the 
arm and forearm. The arm 
is kept in the position of 
acute flexion for about two 
weeks and it is then dressed 
in a position of less flexion, 

and at the end of three or four weeks is simply carried in a 
sling. After this time the arm is gradually extended. This 
method of dressing seems to be followed by the best results 
in fractures of the condyles of the humerus in children. By 
this method of dressing the fragments are firmly held in 
position, better motion is obtained and the tendency to gun- 
stock deformity is diminished. The more extended use of 
this method of dressing fractures of the condyles of the 
humerus has shown that the practical results obtained are 
most satisfactory. 




Showing loss of carrying angle after frac- 
ture of the condyle of the humerus. 



480 FRACTURES 

When fractures of the lower extremity of the humerus 
involve the elbow-joint a certain amount of impairment of 

Fig. 306. 




Fracture of the condyles of the humerus before reduction. 
Fig. 307. 




The same case after reduction with the elbow in acute flexion. 



FRACTURES OF THE HUMERUS 



481 



joint motion is apt to occur either from anchylosis or from 
displacement of the fragments, giving rise to gunstock 
deformity and loss of the carrying angle, which in many cases 
it is impossible to reduce completely, so that flexion and 
extension of the joint are restricted. Bearing these facts in 
mind, it is well to make passive motion in these cases as early 
as the second or third week. It is well to explain to the 
patient or his friends that impairment of joint motion may 

Fig. 308. 




r~~" 





Dressing for fracture of condyles of humerus in acute flexion. 



result in these fractures in spite of the greatest skill and care 
in the treatment. In a case of fracture in the region of the 
condyles of the humerus the dressings should be removed 
in twenty-four hours, and should be redressed in the same 
manner, and if the swelling does not increase and the dressing 
is comfortable to the patient it should afterward be dressed 
at less frequent intervals; the union is generally quite firm 
at the end of four weeks and the splint may be removed at 
this time. Fractures of the condyles of the humerus are 
31 



482 



FRACTURES 



very common in children, and epiphyseal separations of 
the lower epiphysis of the humerus are also met with ; the 
dressing of these injuries in this class of patients is similar to 
that described for fractures of the condyles of the humerus. 

Fractures of the humerus, simple or compound, with 
marked deformity may also be treated by the Thomas splint 
with suspension and traction. This method is of special 
value in those about the surgical neck of the bone. Another 
apparatus and method of extension and suspension are shown 
in Fig. 335). 

Fractures of the Olecranon Process of the Ulna. — Fractures 
of the olecranon may consist in simply a separation of the 
cortical layer of bone over the summit of the process to which 
the triceps is principally attached or the line of fracture may 
pass through the sigmoid fossa. 

Fig. 309. 




Adhesive straps applied in fracture of the olecranon. 



Treatment.— This fracture is dressed with the arm slightly 
flexed at the elbow or with it completely extended ; the former 
position is a little less irksome to the patient. The separation 
of the fragment by the action of the triceps muscle is usually 
not very marked; but, if the displacement is considerable it 
may in a measure be overcome by the use of a compress above 
the fragment, over which figure-of-eight strips of adhesive 
plaster are fastened to draw it down into position (Fig. 309). 
The ends of the strips are then attached to a well-padded 
straight splint which should be long enough to extend from 
the upper third of the arm to the ends of the fingers, and is 
secured in position by the turns of a roller carried from the 



FRACTURES OF THE ULNA 483 

fingers to the upper extremity of the splint, with figure-of- 
eight turns at the elbow to reinforce the action of the strips 
of plaster (Fig. 310). 

This fracture may also be dressed by first applying a pri- 
mary roller to the elbow, and then placing over the arm a 
well-padded anterior obtuse-angled splint, or a straight splint 
with a good-sized pad of lint or oakum fastened at a point 
corresponding to the position of the flexure of the elbow. 
When either of these splints is placed upon the arm a posi- 
tion of moderate flexion is obtained. A compress of lint is 
next placed above the fragment if there is a displacement, and 
one or two narrow strips of adhesive plaster are fastened over 
this and passed obliquely downward and attached to the 

Fig. 310. 




Fracture of olecranon dressed in the extended position. 

splint on either side. The splint is then securely fastened 
to the arm by the turns of a roller bandage applied from the 
fingers to the upper end of the splint. 

The dressings should be removed at the end of twenty-four 
or thirty-six hours, or sooner if there is evidence of swelling 
of the tissues in the region of the fracture, and they should 
be reapplied in the same manner. If the dressing is com- 
fortable to the patient, and there is no evidence of swelling, 
the subsequent dressings should be made at less frequent 
intervals; the dressings are usually retained in this fracture 
for five or six weeks. In compound fractures of the olecranon 
process and in simple fractures where it is found impossible 
to keep the fragment in apposition fixation of the fragments 



484 FRACTURES 

should be secured by suture. Passive motion should not be 
made until this time, as flexion of the elbow tends to separate 
the fragments, unless union has taken place. The union of 
a fracture of the olecranon is in most cases fibrous, but in a 
few instances bony union has been observed. 

Fracture of the Coronoid Process of the Ulna. — Fracture 
of the coronoid process is an extremely rare injury. 

Treatment. — This is accomplished by placing the arm in 
a hyperflexed position and applying a well-padded internal 
acute-angled splint, or an anterior acute-angled splint, and 
securing it to the arm by the turns of a roller bandage. This 
may also be secured by placing the arm in the Jones' position. 
After two weeks the arm should be gradually brought into 
the extended position. A moulded pasteboard or leather 
gutter may be substituted for the angular splint. The dres- 
sings should be changed at intervals, and after their removal, 
at the end of three or four weeks, passive motion should be 
practised. 

Fracture of the Shaft of the Ulna. — This is a very disabling 
injury, as the ulna forms the main part of the elbow-joint, 
and is often associated with a dislocation of the head of the 
radius. The displacement may be backward or forward, and 
is often difficult to correct. The treatment consists in the 
use of a straight splint, applied to the hand and forearm 
with compresses adjusted to correct the displacement of the 
fragments. 

Fractures of the Head and Neck of the Radius. — These 
fractures are also quite rare. 

Treatment. — This consists in reducing the fragments by 
manipulation by flexing the elbow and keeping it in this 
position, and by the application of a well-padded anterior 
right-angled splint, the splint being firmly secured in position 
by the turns of a roller bandage applied from the tips of the 
fingers to the upper end of the splint (Fig. 303) . The splint 
should be changed at intervals and should not be permanently 
removed for four weeks, at which time passive motion, con- 
sisting in flexion and extension at the elbow and pronation 
and supination of the forearm should be made. 

An internal angular splint applied to the inner surface of 






FRACTURES OF THE ULNA AND RADIUS 485 

the forearm and arm may also be used in the treatment of 
these fractures (Fig. 299). The Jones' position also is 
excellent. 

Fractures of the Ulna and Radius.— These fractures are 
often met with as the result of direct or indirect violence. 

Treatment. — After reducing the displacement, which is 
always marked when both bones are broken, by making 
extension from the hand and by manipulation, the forearm 
is placed in the supine position or in a position between pro- 
nation and supination. The supine position is, as a rule, to 
be preferred in any fracture of the radius, as the upper frag- 
ment is supinated by the action of the biceps and supinator 
brevis muscles, and, therefore, unless the lower fragment be 

Fig. 311. 




Dressing for fracture of both bones of the forearm. 

placed in the supine position, union with rotary deformity 
will almost inevitably ensue. 

Two straight wooden splints, well padded, a little wider 
than the forearm, are employed. The anterior splint should 
be long enough to extend from the elbow to the tips of the 
fingers, and the posterior splint should extend from the elbow 
to the wrist. A primary roller should never be applied to 
the forearm in dressing these fractures, as its application 
diminishes the interosseous space, and its use has been 
followed by gangrene of the hand and forearm. In apply- 
ing the anterior splint to the palmar surface of the forearm 
and hand, care should be taken that the upper end of the 
splint does not press upon the brachial artery and basilic 



486 FRACTURES 

vein at the elbow when the forearm is flexed; the posterior 
splint is next applied from the elbow to the wrist and the 
splints are held in position by the turns of a bandage carried 
from the fingers to the elbow (Fig. 311). 

In dressing this fracture a posterior splint equal in length 
to the anterior splint may be used in place of the short 
posterior splint extending from the elbow to the wrist. 

In fracture either of the shaft of the radius or of the ulna 
alone, the deformity is usually not so marked as when both 
bones are broken at the same time, the unbroken bone acting 
as a splint; the dressing for these fractures is the same as for 
fracture of both bones of the forearm. 

In cases where displacement of the fragments and shorten- 
ing is very marked and difficult to correct or maintain, exten- 
sion applied to the forearm and the use of a Thomas splint 
will often prove satisfactory, the patient being confined to 
his bed when this dressing is employed. In some cases expo- 
sure of the fragments and suturing is the only procedure which 
offers a fair prospect of a good result. 

The extension traction method with a Thomas splint and 
the Balkan frame may be employed in cases where the 
deformity is marked and there is difficulty in maintaining the 
correction. The extension bands are fastened to the wrist, 
lower part of the forearm or hand and fingers. 

The dressing should be removed in twenty-four or thirty- 
six hours, and after inspecting the parts and sponging them 
with dilute alcohol the splints should be replaced in the 
same manner and secured. The dressings should be renewed 
at intervals of two or three days for two weeks at least, and 
after this time the dressings should be made at less frequent 
intervals. The time required for union in these fractures is 
usually Rve or six weeks and the splints should be retained 
for this time. 

Incomplete Fractures of the Ulna and Radius. — Green- 
stick Fractures. — In children these fractures are very 
common. 

Treatment. — The deformity is reduced by bending the bones 
back into place, often converting the incomplete fracture 
into a complete one. After reduction of the deformity the 



FRACTURE OF THE RADIUS 



487 



treatment adopted is the same as that described above. In 
these patients there is a great tendency to displace the 
splints or rather to draw the forearm out of the splints, and 
to prevent this I often employ an anterior angular splint in 
place of the straight anterior one, the upper portion of which, 
being fastened to the arm, prevents the child from dragging 
the arm out of the dressings. 

Fig. 312. 




Green-stick fracture of ulna and radius. (Ashhurst.) 



Fracture of the Lower End of the Radius. — The most 
common fracture of the radius is one situated from \ to 1J 
inches above the lower articular surface of the bone (Colles' 
fracture), the line of fracture being more or less transverse, 
although it may in some cases be slightly oblique; the char- 



Fig. 313. 




Fracture of the radius near its lower extremity. 

acteristic deformity in this fracture is represented in Fig. 313. 
Numerous roentgen-ray studies of this fracture have shown 
that it is a much more complicated injury than was formerly 
supposed, being often comminuted or impacted and asso- 
ciated with a fracture of the styloid process of the ulna or 
of the scaphoid or semilunar bones. 



488 



FRACTURES 



Treatment. — The most important point in the treatment of 
this fracture is to effect complete reduction of the fragments 
before the application of any splint; this is done by making 
extension from the hand, and, at the same time, by over- 



Fig. 314. 




Reduction of Colles' fracture of left radius. (Ashhurst.) 

extending and then flexing the wrist and by manipulation 
(Fig. 314) ; the deformity can usually be completely reduced. 
The arm should then be brought into the position of supina- 
tion, and a firm compress of lint is next placed over the lower 
end of the upper fragment on the palmar surface of the fore- 
arm; a second compress is then placed over the upper end 

Fig. 315. 





Position of compress in Colles' fracture. 



of the lower fragment (Fig. 315), and a well-padded Bond 

splint (Fig. 316) is applied to the palmar surface of the arm 

and held in place by the turns of a roller bandage (Fig. 317). 

Many surgeons treat this fracture with the hand in a posi- 



FRACTURE OF THE RADIUS 



489 



tion between pronation and supination, the thumb pointing 
upward. A substitute for Bond's splint may be prepared 
by fastening a roller bandage obliquely upon a straight 
wooden splint as suggested by Dr. Hays (Fig. 318). 



Fig. 316. 




Bond's splint. 
Fig. 317. 




Dressing for fracture of the lower end of the radius. 
Fig. 318. 




Substitute for Bond's splint. 



Jopson reduces impacted Colles' fractures under anesthesia; 
an assistant supports and holds the forearm upon the tri- 



490 



FRACTURES 



angular wooden block, which is used by the orthopedic 
surgeon; the forearm should rest upon this block a little 
distance above the lower end of the upper fragment. He 
then makes overextension and traction, followed by down- 
ward traction and flexion of the wrist and moulds into place 
the fragment or fragments. The completeness of the 
reduction is determined by a roentgen-ray examination. 

Another method of treating Colles' fracture after the reduc- 
tion of deformity consists in placing upon the dorsal surface 
of the forearm a padded stright splint, extending from the 
elbow to the tips of the fingers and a short straight splint 
upon the palmar surface of the arm, extending from the 

Fig. 319. 




Anterior and posterior splints applied. 



elbow to the wrist (Fig. 319). These splints are held in 
position by a bandage, and the forearm carried in a sling 
with the hand inclined to the ulnar side (Fig. 320). The 
hand should be bandaged to the posterior splint for about 
seven days and then set free. The posterior splint should 
be left long for another week; at the end of this time it should 
be shortened so as to extend only to the wrist-joint, and 
the patient should be encouraged to use the fingers and make 
motions of the wrist. At the end of three weeks both splints 
should be removed and the patient should carry the forearm 
in a sling for a few weeks longer and be encouraged to use 
the hand. 
The most important point in the treatment of this fracture 



CHAUFFEUR'S FRACTURE 491 

is the complete reduction of the deformity at the first dressing, 
and if this has been satisfactorily done almost any splint may 
be used with a good result, and, indeed, some surgeons use 
no splint, applying only a compress over the seat of fracture, 
held in place by a strip of plaster, the arm being carried in 
a sling. 

Fig. 320. 




Dressing for Colles' fracture with long posterior and short anterior splint. 

The after-treatment of these fractures consists in remov- 
ing the splint and compresses after twenty-four or thirty-six 
hours and in sponging the surface of the skin with dilute 
alcohol, and the compresses and splints should then be reap- 
plied in the same manner; the fracture should be dressed 
every second or third day for the first two weeks, and after 
this time it should be dressed at less frequent intervals. 
Union is usually quite firm at the end of four weeks, and the 
splint should be dispensed with at this time. A certain 
amount of stiffness of the wrist and fingers is apt to follow 
this fracture, which is usually soon overcome by passive 
motion and physiological use of the parts. 

Epiphyseal Separation. — In children separation of the lower 
epiphysis of the radius is often met with, and its treatment is 
similar to that described above; a Bond splint with com- 
presses or two straight splints with compresses being the most 
satisfactory dressing to employ in this injury, the dressings 
being retained for three weeks. 

Chauffeur's Fracture. — The lower end of the radius is 
often fractured by a backward kick of a motor during the 
act of cranking. The resulting injury is often identical 
with the typical Colles' fracture. Extensive comminution 



492 



FRACTURES 



of the lower end of the radius and marked displacement are 
not uncommon. The treatment is that outlined above for 
Colles' fracture. 

Reversed Colles' Fracture. — This is a rare fracture of the 
lower end of the radius in which the lower fragment is dis- 
placed forward instead of backward, the deformity being the 
reverse of that seen in Colles' fracture. 

Treatment. — This consists in the reduction of the deform- 
ity, the manipulation being the reverse of that employed in 
Colles' fracture, and the dressings are similar to those 
employed in the latter, with the exception that the position 
of the compresses is reversed. 

Fractures of the Carpal Bones. — These fractures are often 
compound or open fractures, and are so frequently associated 
with extensive laceration of the arm and hand that operative 
measures have to be resorted to; but if such is not the case, 
they are dressed, when compound, with an antiseptic dressing, 
and the hand and forearm are supported upon a well-padded 
palmar splint held in place by a roller bandage; more or less 
impairment in the motion of the wrist is apt to follow these 
fractures. The dressings should be retained for three or 
four weeks, and after their removal passive motion should be 
employed to overcome as far as possible the joint stiffness 
resulting. 

Fig. 321. 




Agnew's splint for fracture of the metacarpal bones. 



Fractures of the Metacarpal Bones. — These fractures are 
often met with as the result of direct or indirect force applied 
to the metacarpal bones. 

Treatment. —This consists in first reducing the deformity, 
which is usually an angular one, the projection of the angle 
being toward the back of the hand; this is reduced by pressure 
with the fingers, and the hand and forearm should then be 
placed upon a palmar splint (Fig. 321) with a pad of oakum 
or cotton under the palm; a compress of lint is next placed 



FRACTURES OF THE PHALANGES 



493 



over the seat of fracture, and the hand and forearm are bound 
to the splint by the turns of a roller bandage (Fig. 322) . At 
the end of three weeks union at the seat of fracture is usually 
quite firm, and the splint should be dispensed with at this 
time. 

Fig. 322. 




Dressing for fractures of the metacarpal bones. 

Fractures of the Phalanges. — These may result from direct 
or indirect violence, and often present marked deformity. 

Treatment. —This consists in reducing the displacement 
by extension and manipulation, and in placing the finger in a 
moulded gutta-percha or pasteboard splint (Fig. 323), and 
securing the splint in position by the turns of a roller bandage. 
When the proximal phalanx is fractured, a narrow padded 

FiG. r 323. 




Gutta-percha splint for fracture of phalanx. 

wooden splint extending from the end of the finger to the 
wrist should be applied upon the palmar surface of the finger 
and hand, and a short dorsal splint should also be used; if 
there is a tendency to lateral displacement, short lateral 
splints should also be employed, and the splints should be 
held in place by strips of plaster or by a^roller bandage (Fig. 



494 FRACTURES 

324) . Splints made from a loop of wire may be fitted to the 
finger, padded, and secured in the same manner. A Woman's 
hair pin, wrapped with adhesive plaster also makes a very 
satisfactory splint as it can be bent to fit the finger accurately. 
Union in fractures of the phalanges is usually firm at 
the end of three weeks, and the splints can be dispensed with 
at that time. 

Fig. 324. 




Dressing for fracture of phalanx with anterior and posterior splints. 

FRACTURES OF THE LOWER EXTREMITY. 

Fractures of the Femur. — These may involve the neck, 
great trochanter, and upper end of the shaft, the shaft, or the 
lower extremity of the bone. 

Fractures of the shaft of the femur are common in children, 
those of the upper extremity of the bone involving neck and 
intracapsular fractures are rare in children but common in 
adults, especially in adults over sixty years of age. Trivial 
accidents such as twisting the limb or slight falls upon the 
trochanter, frequently produce this variety of fracture. 
Inpaction of the fragments is not uncommon. 

Fractures of the Upper Extremity of the Femur. —These may 
involve the head, neck, the great trochanter, and the upper 
portion of the shaft of the femur. Muscular spasm, localized 
pain and tenderness, eversion of the lower extremity, moder- 
ate shortening which may be progressive and relaxation of 
the fascia lata above the trochanter, as pointed out by Allis 
are suggestive of this lesion. Roentgen-ray examination 
should be made in all cases. As many of these fractures 
are impacted, especially those involving the region of the 
trochanter, the question of its treatment must be considered. 



FRACTURES OF THE LOWER EXTREMITY 495 

In the aged it is better not to relieve the impaction, but in 
children and vigorous adults under sixty years of age, better 
results may be obtained, by breaking up the impaction and 
dressing the limb in extreme abduction. 

Treatment.— The patient should be placed in bed upon a 
firm mattress, and an extension apparatus made from adhe- 
sive plaster should be applied to the leg, extending as far as 
the knee-joint. The extension apparatus is constructed by 
taking a piece of adhesive plaster 2J inches in width and 
long enough to extend from the outer side of the knee or 
middle of the thigh to 4 inches below the sole of the foot, 
and from this point back to the inner side of the knee or 

Fig. 325. 




Adhesive plaster extension apparatus applied to limb. 



middle of the thigh; in the center of this strip is placed a 
block of wood, 2| inches wide and 4 inches in length, with a 
perforation in its center; the block and the inner surface of 
the strip on each side are next faced with a similar strip of 
adhesive plaster to a point about 1 inch above each malleolus; 
a few straps are next wound around the wooden block to fix 
the previously applied straps; the strip of plaster is next 
warmed and applied to the sides of the leg and held in posi- 
tion by three or four strips of adhesive plaster carried around 
the leg at intervals; the strips may be applied to extend only 
to the knee (Fig. 325), and the plaster is made additionally 
secure by the application of a roller bandage applied to the 



496 FRACTURES 

foot and leg and carried up to the knee. Volkmann's sliding 
foot-piece may be employed to make the extension more 
effective. 

Through the perforation in the block or stirrup is fastened 
a cord which passes over a pulley attached to the bed, and 
to this cord is attached the extending weight. The extension 
apparatus being applied, lateral support is given to the leg 
and thigh by sand bags applied on either side; the outer sand 
bag should extend from the foot to the axilla, and the inner 
one from the foot to the groin. A weight of 5 or 10 pounds 
is attached to the extending cord, and the lower feet of the 
bed should be raised on blocks a few inches high, to prevent 
the patient from slipping down in bed; a pad of oakum or 
cotton should also be placed under the tendo Achillis, to 
relieve the heel from pressure. This dressing is kept in place 
for from four to six weeks, and if union has occurred the 
patient is kept in bed for a few weeks longer and is then 
allowed to be about, using crutches. In the majority of 
cases of fracture of the neck of the femur fibrous union only 
takes place, and after employing the dressing before described 
for six weeks the patient is allowed to get up and go about on 
crutches. It often happens that the subjects in whom these 
fractures occur are old and feeble, and if it is found that 
restraint in bed with the dressings here described is not well 
borne, as these subjects are apt to develop hypostatic 
pneumonia and bedsores, under such circumstances they 
should be discarded and the patient allowed to sit up in bed 
with the limb resting on a pillow, or to get into a chair, the 
treatment of the local condition having to be disregarded, 
attention being given to the patient's constitutional condition. 

Whitman has advocated the abduction treatment of 
fractures of the neck of the femur in the aged as well as the 
young. This treatment has been extensively used in recent 
years and the results show the soundness of his judgment. 
He abducts the limb under anesthesia and encases the entire 
lower extremity and pelvis in a plaster-of-Paris dressing, the 
bony prominences, pelvis and upper thigh being covered by 
a layer of felt before the plaster is applied. This dressing is 
remarkably well borne by old people and their care in bed is 



FRACTURES OF THE LOWER EXTREMITY 497 

much simplified by the ease with which they may be moved. 
The head of the bed should be raised or they should be 
propped up to guard against hypostatic pneumonia. The 
position of the limb and the extent of the dressing is shown 
in Figure 326 

In fractures in the upper portion of the femur where 
there is marked tilting forward of the upper fragment, Profes- 

Fig. 326. 




Abduction cast in fracture of neck of femur. (Ashhurst.) 



sor Agnew employed extension made from the thigh and 
placed the limb upon a double inclined plane, maintaining 
this position during the treatment of the case (Fig. 327). 
With the same object in view, in place of the double inclined 
plane a double inclined fracture-box may be employed (Fig. 
328), extension being made from the thigh by means of 
adhesive plaster strips applied above the knee, to which a 
weight is attached. 
32 



498 



FRACTURES 



Fracture of the Shaft of the Femur. — This is a frequent 
fracture, and is usually accompanied by marked shortening 
and angular or rotatory displacement of the fragments. This 
fracture which is common in children and adults, but rare 



Fig. 327. 




- Tp 

Dressing of fracture of the femur with extension upon an inclined plane. 

in the aged, is evidenced by shortening often as much as 4 or 
5 inches, anterior or lateral displacement, and rotation of 
the limb. 

Treatment.— The patient should be placed upon a fracture- 
bed or an ordinary bed with a firm hair mattress; an extension 
apparatus of adhesive plaster is applied, and extension is 

Fig. 328. 




Double inclined fracture-box. 



made by a weight attached to this, as previously described. 
The amount of weight attached to the extension apparatus 
should vary, in a muscular adult much more weight is required 
than in an adult with weak muscles or a child. Ten to 25 



FRACTURES OF THE LOWER EXTREMITY 



499 



pounds are usually required. Lateral support is given to the 
limb by the application of two wooden splints — the outer or 
long one extending from the axilla to the foot, the inner or 
short one extending from the groin to the foot. The splints 
at their upper extremity should be about 6 inches in width 
and at their lower extremity about 3 J inches. The splints 
are wrapped in a splint cloth, which extends from the foot to 
the groin, and after this has been placed under the limb the 
splints are fixed in their proper positions, the short one to 
the inner side, the long one to the outer side of the limb. 
Between the limb and the splints are interposed bran bags: 
the outer bag should be long enough to extend from the 

Fig. 329. 




Dressing for fracture of the shaft of the femur with lateral splints and bran bags. 



axilla to the foot, the inner one from the groin to the foot. 
The splints and bran bags are held in place by five or six 
strips of bandage passing under the limb and body and 
around the splints and bran bags at intervals. The heel 
is saved from pressure by placing a wad of oakum or cotton 
under the tendo Achillis, and after the splints have been 
brought into place the strips of bandage are firmly tied to 
secure them, and a weight of 10 to 25 pounds is attached to 
the extending cord. The foot of the bed is raised, to prevent 
the patient from slipping downward and to allow the weight 
of the body to act as a counter-extending force. After 
the application of the dressings the thigh should be slightly 



500 FRACTURES 

abducted. During the after-treatment of these fractures the 
surgeon should see that the splints and bran bags are kept 
firmly in place, and that the foot does not roll outward; this 
is accomplished by untying the strips and readjusting the 
bags, and then bringing up the splints and securing them in 
position by fastening the strips (Fig. 329). The extension 
apparatus usually does not require renewal during the course 
of treatment. The extension apparatus and splints are kept 
in place for four or six weeks, and at this time union at the 
seat of fracture is usually quite firm, so that they may be 
removed, and the fracture is then supported by moulded 
pasteboard splints or by the application of a plaster-of-Paris 
splint for several weeks longer, and at the end of eight to 
ten weeks it is safe to allow the patient to be up and around 
on crutches. The x-ray should be employed to verify satis- 
factory position of the fragments. 

Suspension Traction Treatment of Fractures of the Long 
Bones near Joints. — This form of treatment of fractures of 
the long bones has been used during the last few years, and 
is at the present time extensively employed, and the results 
obtained are most satisfactory. The traction suspension 
treatment affords the best means of placing the distal frag- 
ment in proper alignment with the proximal fragment. It 
also provides for the care of the damaged soft parts, recog- 
nizing the fact that in many cases muscular, fascial and joint 
repairs are as important in restoring a good functioning 
limb as anatomical restitution of the bone. 

This treatment requires special apparatus, experience in 
their use, with attention to detail, which requires a con- 
siderable expenditure of time, but those surgeons who have 
used it extensively consider that it is justified by the results. 
Traction may be applied by adhesive plaster attached to the 
skin, or by strips of canton flannel fastened to the skin by 
Sinclair's or Heussner's glue, or the Henniquen band around 
the flexed elbow in fractures of the humerus; and in fractures 
of the femur or bones of the leg, by means of the Ransohoff 
tongs (Fig. 330), or the Worcester modification of the same. 
This consists in making the points conical, to prevent too 
deep penetration. Suspension is obtained by the Thomas 



FRACTURES OF THE LOWER EXTREMITY 501 

arm (Fig. 331) or thigh splint (Fig. 332), or Hodgen's splint 
and the Balkan frame. 

A preliminary roentgen ray is taken. In treating a fracture 
of the femur by this method the immediate application of 
sufficient weight to overcome shortening is most important. 

Fig. 330. 




Ransohoff's tongp. 
Fig. 331. 




Thomas' arm splint. 
Fig. 332. 




Thomas' traction leg splint. 



In an adult male an initial weight of 25 pounds is often 
required; this can be diminished later if a subsequent 
roentgen ray shows that the shortage has disappeared or is 
diminishing. In fractures of the humerus from 8 to 10 
pounds is usually sufficient. 

Fractures of the bones of the leg are usually drawn into 



502 



FRACTURES 



direct alignment without difficulty, but in certain fractures 
of the femur or humerus, to correct the deformity, traction 
must be made at different angles to the body (Fig. 333). 
Special additions to the Balkan frame permit traction at any 
angle with the trunk. 

Fig. 333. 







Thomas' splint suspension in abduction. (Splint Manual, U. S A.) 

The extension apparatus may be made with Z. O. plaster, or 
by attaching strips of canton flannel to the skin by Sinclair's 
or Heussner's glue, which is painted upon the skin, and as it 
begins to dry the canton flannel strip is applied. Sinclair's 
glue is composed of glue, 50 parts; water, 50 parts; glycerin, 
2 parts; calcium chloride, 1 part; and thymol, 1 part. Heuss- 
ner's glue is made of resin, 50 parts; alcohol (90 per cent), 



FRACTURES OF THE LOWER EXTREMITY 503 

50 parts; Venice turpentine, 1 part and benzine, 1 part. In 
applying the tongs or caliper extension in fracture of the 
femur or bones of the leg, the tongs are usually applied to the 
condyles or to the malleoli (Fig. 334); the skin in the 
region is sterilized and painted with tincture of iodine, and a 

Fig. 334. 




Method of treating high fractures of the femur with the Hodgen's splint and traction 
by Ransohoff's tongs. Abduction is obtained by placing the pulley for the traction 
cord on an outrider, and outward rotation by tilting the splint. The suspension attach- 
ment for preventing foot-drop has not been drawn. (The more proximal of the distal 
suspension cords should have been attached to the splint at the proximal side of the 
knee.) (Blake.) 

small amount of novocaine is injected into the tissues at the 
seat of application. A narrow knife is passed down the bone, 
and the points of the tongs are introduced and driven into 
the bone. A sterile gauze dressing is secured around the 
puncture points. 



504 



FRACTURES 



In fractures of the leg the tongs may be applied to the 
malleoli, or to the os calcis. The limb is next placed upon a 
Thomas or Hodgen's splint, and suspended from the Balkan 
frame. Extension is made by attaching a weight to the 
tongs, or other extension apparatus, by a system of pulleys 

Fig. 335. 




Fracture of the humerus in suspension and traction. (Ashhurst.) 



attached to the Balkan frame and splint. The patient can 
change his position in bed without interfering with the 
extension or disturbing the fragments. In certain cases 
joint movements can also be accomplished. In fractures 
of the humerus and bones of the forearm, the suspension 
traction treatment may be employed with good results. 



FRACTURES OF THE LOWER EXTREMITY 505 

Many surgeons, in fracture of the shaft of the femur, prefer 
to use a long external sand bag, and a shorter internal one in 
place of the corresponding long and short splints and bran 
bags; if care is observed that the sand bags are kept accurately 
in contact with the limb and body, excellent results may be 
obtained by this form of dressing. After considerable 
experience with both methods of furnishing lateral support, 
in the dressing of fractures of the shaft of the femur, I am well 
satisfied that angular deformity is less likely to result where 
the splints and bran bags are employed. 

Plaster-of -Paris Dressing.— In applying this as a primary 
dressing it is essential that the patient be anesthetized to 
reduce muscular spasm and extension, and manipulation 
should be made until the fragments are in accurate apposi- 
tion; and a plaster-of-Paris bandage should be applied, 
including the foot, leg, thigh, and pelvis, extension being 
maintained under anesthesia until the bandage has become 
firm. In applying this dressing, the patient should be placed 
upon the pelvic supporter (see page 107). 

Fracture of the Lower End of the Femur. — The fractures 
met with in this portion of the femur are supracondyloid 
fractures, those in which one condyle is separated from the 
other, or comminuted fractures, in which both condyles are 
separated; epiphyseal disjunctions of the lower end of the 
femur, met with in young subjects, may also be classed with 
fractures at this portion of the bone. 

Treatment. —To reduce the deformity and approximate 
the fragments by extension and manipulation the use of 
an anesthetic is necessary. If there is shortening, the 
dressing should be similar to that employed in fractures of the 
shaft of the femur, consisting in the application of an exten- 
sion apparatus and bran bags and splints or sand bags to 
give lateral support; if, however, there is no marked shorten- 
ing, the dressing employed should be the same as that applied 
in fractures involving one or both condyles or epiphyseal 
separation. Where there is marked deformity the suspension 
traction treatment and tongs may be employed with good 
results. 

The dressing employed in fracture of one or both condyles, 



506 FRACTURES 

or in epiphyseal disjunction of the lower end of the femur, 
consists in placing the limb in a fracture-box extending from 
the foot to the upper third of the thigh, the box being well 
padded with a soft pillow, or a well-padded posterior splint, 
or a moulded pasteboard or felt gutter may be employed; 
if either of these dressings is employed, the splint or gutter 
should be sufficiently long to extend from the lower part of 
the leg to the upper part of the thigh. 

At the end of ten days or two weeks it is well to place the 
limb in a plaster-of-Paris dressing extending from the foot 
to the upper part of the thigh. This dressing should be 
retained for six to eight weeks; at the end of this time the 
dressing should be removed, and if union is sufficiently firm 
to allow the patient to go about on crutches, a fresh plaster- 
of-Paris splint should be applied, extending from the middle 
of the leg to the middle of the thigh, or lateral splints of paste- 
board may be substituted for the plaster dressing. The 
plaster-of-Paris dressing may be applied as a primary dressing 
after the reduction of the fracture under anesthesia, if there 
is not much swelling of the parts. 

A certain amount of permanent impairment of the joint- 
motion is apt to follow fractures involving one condyle or 
both condyles of the femur. 

Fracture of the Shaft of the Femur in Children. — Treat- 
ment.— In infants the treatment by extension by a weight 
and pulley and lateral splints is often unsatisfactory on 
account of the difficulty in keeping the patient quiet upon his 
back, and from the soiling of the dressings by the feces and 
the urine. In children two years of age and over I have never 
found much trouble in employing extension and lateral sup- 
port by splints and bran bags or sand bags, and in these cases 
I make additional fixation at the seat of fracture, and guard 
against displacement of the fragments by the child sitting up 
in bed when not watched, by carefully moulding external 
and internal pasteboard or felt splints to the thigh, and hold- 
ing them in place by the turns of a bandage. I have 
employed this form of dressing even in children under two 
years of age with the most satisfactory results. 

In cases of fracture of the femur in children from a few 



FRACTURES OF THE LOWER EXTREMITY 



507 



Fig. 336. 



months to a year or eighteen months of age, in whom it is 
difficult to obtain quietude, or who have to be moved to give 
them nourishment if they are taking the breast, the dressing 
which I have found most satisfactory consists in first applying 
a roller bandage from the foot to the groin, and then moulding 
to the outer half of the foot, leg, thigh, and also to half of the 
pelvis, a pasteboard or felt splint which is well padded with 
cotton, and held in position by the turns of a bandage carried 
from the foot to the pelvis and finished with circular turns 
about the pelvis. The splint should be so moulded as to 
include a little more than one-half of the 
circumference of the thigh and leg. If 
this splint becomes soiled, it is easily re- 
placed by a fresh one, and its removal and 
renewal are much easier than the plaster- 
of -Paris splint. 

In young children fractures of the femur 
are often incomplete or green-stick fractures; 
and even when complete, the shortening 
is usually not marked, as the line of frac- 
ture is apt to be transverse, the peri- 
osteum often not being completely rup- 
tured, which tends to hold the fragments 
in position. 

In green-stick fractures the deformity 
should be reduced by manipulation, even 
if it is necessary to convert the incomplete 
fracture into a complete one to accom- 
plish this object. 

Mr. Bryant recommended that fractures of the femur in 
young children be treated in the vertical position; the injured 
limb, together with the sound one, is flexed at a right angle 
to the pelvis and fixed with a light splint, and attached to a 
cradle or bar above the bed (Fig. 336) . 

Plaster-of -Paris Dressing. —This is a very satisfactory 
dressing. The patient should be anesthetized, and after 
reduction of the fragments by extension and manipulation, 
the limb should first be enveloped from the foot, including 
the pelvis, with a flannel bandage, extension being made while 




Fracture of the 
femur treated by ver- 
tical extension. 



508 FRACTURES 

the plaster-of-Paris bandage is being applied, and should be 
kept up until the bandage has become fixed. The plaster 
bandage should include the whole limb and the pelvis, so as 
to fix the hip-joint. To prevent the splint from absorbing 
the discharges and becoming offensive, the upper portion 
of it may be coated with shellac. 

The time required for union in fractures of the femur in 
children is about four weeks, and the dressings may be 
removed at this time; but the child should not be allowed to 
use the limb for eight or ten weeks from the receipt of the 
injury, on account of the risk of consecutive shortening or 
angular deformity from bending of the bone at the seat of 
fracture. 

Ambulatory Treatment of Fracturs of the Femur.— In this 
method of treatment in fractures of the femur the injured 
limb is strongly extended, and a flannel roller is applied to 
the leg, thigh and pelvis. A plaster-of-Paris bandage is 
then applied from the toes to the pelvis, and is made to 
include the pelvis by spica and circular turns. It should be 
well padded in the perineum, and the inner portion of the 
bandage should fit well in the region of the tuberosity of the 
ischium. The plaster dressing should be so applied that 
upon the patient standing upon the limb the weight is 
supported by the plaster cast resting upon the tuberosity 
of the ischium, and the expanded portion of the ilium. A 
Taylor hip-splint, reinforced by plaster bandages and the 
use of crutches, with a high shoe on the sound foot, may be 
used in the ambulatory treatment of fractures of the femur. 

Fracture of the Patella. — These fractures result from direct 
violence and muscular action, in the latter the lateral fibrous 
extensions of the quadriceps are freely torn which causes 
wide separation of the fragments. The line of fracture is 
more or less transverse and the lower fragment is usually 
smaller. This fracture is rarely seen in children except 
when produced by direct violence. 

Treatment.— As it is difficult to secure good apposition of 
the fragments by reason of the interposition of tissues between 
the fragments, the operative treatment gives the best results 
and is generally employed. In old persons and those suffer- 



FRACTURES OF THE LOWER EXTREMITY 



509 



ing from visceral disease the conservative treatment which 
often is followed by a very useful limb, should be preferred. 
This consists, first, in the application of a roller bandage 
from the toes to the upper part of the leg; a well-padded 
posterior wooden splint long enough to extend from the 
middle of the leg to the middle of the thigh, or an Agnew 
splint, which is provided with pegs for the attachment of 
strips of adhesive plaster (Fig. 337), is next placed under the 
limb. A small compress of lint is next placed above the upper 
fragment, and a similar compress is placed below the lower 
fragment; a strip of adhesive plaster 1\ inches in width and 
24 inches in length has its middle portion applied over the 
compress, and its ends are then brought obliquely downward 
and fastened to the splint, or to the pegs if Agnew's splint 



Fig. 337. 




Agnew' s splint for fracture of the patella. 

be used; this may be reinforced by a second or third strip. 
The object of these strips is to bring the upper fragment down 
in contact with the lower fragment. A strip of plaster with 
the ends passing in the opposite direction is next placed over 
the lower compress, and the ends are fastened to the splint 
or pegs; this strip serves only to steady the lower fragment, as 
it cannot be drawn upward to meet the upper fragment by 
reason of the inextensibility of its ligamentous attachment 
(Fig. 338). If the Agnew splint is employed, the strips of 
plaster may be tightened by turning the pegs to which they 
are fastened without removing the splint. 

The splint is next firmly fixed in contact with the limb by 
the turns of a roller bandage extending from the lower to the 
upper end of the splint. The limb should next be placed 



510 



FRACTURES 



upon an inclined plane or in a long fracture-box, with its foot 
elevated to relax the quadriceps femoris muscle. This 
dressing should be removed and reapplied in a few days, as 
the dressings become loose as the swelling about the seat of 
injury subsides, and after this disappears the dressings require 
renewal at less frequent intervals; and usually at the end of 
three weeks the splint may be removed and a plaster-of-Paris 
bandage may be applied, extending from the middle of the 
leg to the middle of the thigh. At the end of six weeks the 
patient may be allowed to walk upon the limb, the knee-joint 
being fixed with a plaster-of-Paris or pasteboard splint. 

It is well, after removal of the splints, for the patients to 
wear for some months a laced muslin knee-supporter, which 
gives some support to the knee-joint. 



Fig. 338. 




Agnew's splint applied. 



A great variety of splints have been devised and used 
in the treatment of fractures of the patella, the main object 
of which is to fix the knee-joint and bring the fragments as 
nearly as possible in apposition. 

The union in fractures of the patella is usually fibrous, 
although in rare cases bony union has occurred. 

In cases of rupture of the fibrous union after fracture of 
the patella, which is not an uncommon accident, the treat- 
ment of the case should be the same as that for a recent 
fracture of the patella. 

Operative Treatment.— This method, which consists in 
exposing the fragments by an incision and drilling and sutur- 
ing them with catgut or silver-wire sutures, or in approxima- 



FRACTURES OF THE LOWER EXTREMITY 511 

ting the fragments by suturing the fibrous tissues with catgut, 
is the most satisfactory procedure and the one often employed 
at the present time, the strictest antiseptic precautions being 
taken to prevent infection of the wound. After the external 
wound has been closed without drainage, the limb is put up 
in a plaster-of-Paris dressing extending from the foot to the 
groin. Or the limb may be placed upon a straight splint 
extending from the middle of the leg to the upper third of the 
thigh, this may be used for ten days, and after the sutures 
have been removed a plaster-of-Paris dressing is applied for 
a few weeks. 

Rupture of the Quadriceps Extensor Tendon. — This usually 
results from muscular force, the tendon giving away instead 
of the patella, the tendon may tear just above the patella 
or its attachments to the bone may be separated. I have 
seen a patient who sustained a simultaneous rupture of both 
tendons. The symptoms are a depression above the patella, 
pain, inability to extend the leg or to stand or walk. The 
treatment in vigorous subjects is exposure of the ruptured 
tendon and suture; in aged or debilitated subjects this should 
be the same as that of fracture of the patella. 

Fractures of the Tibia. — These may result from direct or 
indirect force, the line of fracture may be transverse, spiral 
of oblique. Those of the upper and lower portion may 
involve the knee-joint and ankle-joint. If the fibula is 
uninjured the deformity is not apt to be marked. The 
treatment is practically the same as that for fracture of both 
bones of the leg. 

Fractures of the Tibia and Fibula. — In fractures of both 
bones of the leg the displacement is usually very marked. 
When only one bone is broken, the sound bone, acting as a 
splint, prevents much deformity, except in cases of fracture 
at the lower end of the fibula, when the foot inclines to the 
injured side. 

Treatment.— The dressing of fractures of both bones of 
the leg, or of fracture of the tibia or the fibula alone, except 
in cases where the lower portion of the fibula is the seat of 
injury, is best accomplished by the use of a fracture-box. 
The displacement being overcome as far as possible by 



512 



FRACTURES 



extension and manipulation, the leg is placed in a fracture- 
box, which is prepared for the reception of the limb by having 
the sides let down and having a soft pillow laid in it; the foot 



Fig. 339. 




Application of the fracture-box. 



is next secured to the footboard by a loop of bandage passed 
around the foot, the ends being tied after passing through 
the slots in the footboard; a. pad of oakum or cotton is placed 



Fig. 340. 





Plaster bandange applied to fracture of the leg. 



under the tendo-Achillis, to relieve the heel from pressure, 
and a similar pad is placed between the sole of the foot and the 
footboard (Fig. 339) . The sides of the box are then brought 



FRACTURES OF THE LOWER EXTREMITY 513 

up and secured by two or three strips of bandage tied around 
the box. In using a fracture-box in the treatment of fractures 
of the bones of the leg the surgeon should see that the foot is 
kept well down to the footboard and is at a right angle with 
the leg, that there is no eversion of the knee, and that the 
pillow is full enough to make equable pressure upon the leg 
when the sides of the box are secured, and that the heel is 
not subjected to undue pressure, the use of a pad of oakum 
or cotton under the tendo Achillis being employed to prevent 

Fig. 341. 




Fracture-box suspended. 



this complication. Where there is a tendency to tilting 
upward of the lower end of the upper fragment, the lower 
fragment can be brought in line with this by raising the foot 
by a mass of oakum or cotton placed under the tendo Achillis 
and heel, and so overcoming the deformity. In some cases 
division of the tendo-Achillis may be required before this 
deformity can be corrected. 

The subsequent dressings of the case are conducted by 
letting down the sides of the box and correcting any displace- 
ment, if present, by adjusting the limbs and pads in their 
33 



514 FRACTURES 

proper position, and again bringing up the sides of the box 
and securing them. At the end of two weeks the fracture box 
may be removed and a plaster-of-Paris dressing applied to the 
limb, which will allow the patient more freedom of move- 
ment in bed or permit of his sitting up without disturbing 
the fragments (Fig. 340) . 

Union in fracture of the bones of the leg is usually quite 
firm in six weeks, but for at least eight weeks the patient 
should not be allowed to put his weight upon the limb in 
walking. 

If the patient is restless, and finds his position with the 
fracture-box resting upon the bed irksome, the fracture-box 
may be swung from a frame fastened over the bed (Fig. 341) . 

Plaster-of-Paris Dressing. —This dressing is extensively 
used in the treatment of fractures of the tibia or the tibia and 
fibula. 

The deformity should first be corrected by extension and 
manipulation. To accomplish this an anesthetic is usually 
required, bony prominences are padded with layers of cotton, 
and a flannel bandage is applied to the limb from the toes to a 
point a little above the knee-joint. The plaster-of-Paris 
bandage is next to the limb from the toes to the thigh, and 
extension should be maintained until the bandage has set. 
The case should be under constant observation for a few days, 
so that the dressing can be removed if a dangerous amount 
of swelling takes place. 

Moulded lateral splints of felt or pasteboard are also 
sometimes applied in the treatment of these cases (Fig. 342) . 

In patients suffering with delirium tremens, or in maniacal 
patients, the use of a fracture-box in the treatment of frac- 
tures of the bones of the leg is often not satisfactory, on 
account of the difficulty in restraining the movements of the 
patient and the consequent displacement of the fragments. 
In such cases it is well to apply a few strips of binders' board, 
well padded with cotton, to the limb, extending above and 
below the seat of the fracture, holding them in place by a 
few turns of a roller, and then to wrap the limb and foot in 
a soft pillow, and hold this in place by the turns of a roller 
bandage applied with moderate firmness. This dressing 



FRACTURES OF THE LOWER EXTREMITY 515 

allows the patient to move the limb without serious disturb- 
ance of the fragments, and, after the patient recovers from 
his attack, the leg may be placed in the fracture-box or in a 
plaster-of-Paris dressing. 

In fractures of the bones of the leg in young children the 
same difficulty is often experienced in keeping them quiet, 
and for this reason a fracture-box cannot be used with 

Fig. 342. 




Moulded binders' board splints for fracture of the leg. 



satisfaction. In dressing these cases, two lateral splints of 
pasteboard, moulded to the foot and leg and well padded with 
cotton, may often be employed with the best results. The 
splints should not be wide enough to meet on the anterior or 
posterior surface of the leg or foot. The splints, after being 
carefully adjusted, are held in place by the turns of a roller 
bandage; and after these splints have been applied for two 
weeks, and all swelling has subsided at the seat of fracture, 



516 FRACTURES 

a plaster-of-Paris bandage may be substituted for them, which 
should be worn for four weeks; at the expiration of this time 
union is usually sufficiently firm to dispense with all dressings. 

Plaster-of-Paris Dressing. —This may be used as a primary 
dressing, and is applied in the same manner as for similar 
fractures in adults. 

Ambulatory Treatment of Fractures of the Bones of the Leg. — 
The application of a dressing for the ambulatory treatment 
of fractures of the bones of the leg is as follows : The fracture 
should be reduced and the skin of the leg washed with soap 
and water; a flannel bandage is applied from the toes to a 
point just above the knee. This bandage holds to the sole 
of the foot a number of layers of cotton wadding, which, 
when moderately compressed, makes a pad f of an inch in 
thickness. A plaster-of-Paris bandage is applied to the foot 
and leg, and extends above the knee, and care should be taken 
to apply additional turns about the sole of the foot and ankle, 
to give it greater strength at these points. The turns of the 
bandage should also be firmly applied about the expanded 
head of the tibia. 

In the ambulatory method of treatment, the patient, as 
soon as the bandage has become firm, is allowed to walk 
about, first with crutches or a cane, and finally bearing his 
weight upon the injured limb. 

Fractures of the Fibula. — Fractures of the shaft of the 
fibula are rare, but very frequent in association with fractures 
of the tibia, and are quite common in the lower fifth of the 
bone. In isolated fracture of the upper part of the shaft 
of the fibula it is often difficult to secure apposition of the 
fragment, as they are buried in the muscles, and delayed 
union or non-union is not uncommon. The deformity is not 
marked, and they are usually dressed with a fracture-box 
applied as in the dressing of fractures of both bones of the leg, 
and at the end of two weeks a plaster-of-Paris dressing should 
be applied, and the patient allowed to get out of bed and 
move about on crutches. The plaster-of-Paris dressing may 
also be Used as a primary dressing. The union in a fracture 
of the fibula is usually quite firm at the end of five weeks, at 
which time all dressings may be dispensed with. 



FRACTURES OF THE LOWER EXTREMITY 517 

Fracture of the Lower End of the Fibula (Pott's Fracture). 
—This fracture usually occurs in the lower fifth of the bone, 
and is often associated with laceration of the internal lateral 
ligament of the ankle-joint or a fracture or sprain-fracture 
of the internal malleolus, and is usually accompanied by 
marked eversion of the foot. 

Treatment.— After reducing the displacement by extension 
and manipulation, the limb should be placed in a fracture- 
box provided with a soft pillow, the foot should be secured 
to the footboard, and a pad of oakum or cotton should be 
placed under the tendo-Achillis : before bringing up the sides 
of the box and securing them, two firm compresses of lint or 
oakum should be placed in contact with the leg and foot, 
one just above the inner malleolus, the other just below the 
outer malleolus. The sides of the box are next brought up 
and secured, and by the pressure of these compresses the foot 
is brought into an inverted position and the deformity is 
corrected. 

The after-dressing of this fracture consists in letting down 
the sides of the box, and in inspecting the parts to see that 
the foot is kept in the proper position, and care should be 
taken that undue pressure is not made upon the skin by the 
compresses, which might result in ulceration; this may be 
avoided by sponging the skin with alcohol and changing the 
positions of the compresses slightly at each dressing. At the 
expiration of ten days the fracture-box and compresses may 
be removed and the limb put up in a plaster-of-Paris dressing, 
including the foot and leg, up to the knee. The patient may 
then be allowed to go about on crutches, and at the end of 
five weeks all dressings may be dispensed with. 

This fracture may also be treated by the forcible correction 
of the deformity under ether and the immediate application 
of a plaster-of-Paris dressing. 

Dwpuytren's splint, which consists of a straight wooden 
splint long enough to extend from the condyles of the femur 
to the end of the toes, may also be employed; this splint is 
provided with padding, the thickest part of which, several 
inches in thickness, should rest upon the skin just above the 
inner malleolus when the splint is applied to the inner side 



518 



FRACTURES 



of the leg. The splint is secured in position by the turns of 
a roller applied over the foot and at the upper part of the leg 
(Fig. 343). After using this dressing for a few days, if the 
displacement is satisfactorily corrected, the splint may be 
removed and the leg placed in a fracture-box or in a plaster- 
of-Paris dressing. 

Fig. 343. 




Dupuytren's splint applied. 

Fractures of the Tarsal Bones. — The calcaneum and 
astragalus are the tarsal bones most frequently fractured. 

Treatment.— The dressing of fractures of the calcaneum, 
after reducing the displacement, which is not usually marked 
unless the posterior portion of the bone is involved, by 
manipulation, consists in placing the leg and foot in a fracture- 
box, care being taken that the foot is kept at a right angle to 
the leg. When the fracture involves the posterior portion of 
the bones, and there is displacement by the action of the 
muscles inserted into the fragment, the leg should be flexed 
upon the thigh and the foot extended; this position may be 
maintained by applying a well padded curved splint to the 
anterior portion of the leg and foot and securing it in position 
by a bandage. 

Fractures of the astragalus, after reducing any deformity 
which is present by extension and manipulation, are dressed 
by placing the foot and leg in a fracture-box, care being 
taken that the foot is kept at a right angle to the leg. This 
precaution is important, as anchylosis not infrequently 
occurs after this fracture, and if the foot is in the proper 
position it is much more useful to the patient. 

As soon as the swelling, which is usually very marked after 
fracture of the calcaneum or astragalus, subsides, the foot 
and leg should be put up in a plaster-of-Paris bandage. The 
amount of tension and the inability to reduce the displace- 



COMPOUND OR OPEN FRACTURES 519 

ment in cases of fracture of the astragalus may be indications 
for excision of the fractured bone. The time required for 
union in fractures of the tarsal bones is from five to six weeks. 

Fractures of the Metatarsal Bones. — These fractures are 
dressed by placing the foot upon a well-padded plantar splint, 
and using compresses to hold the fragments in place if there 
is much displacement, the splint and compresses being held 
in position by a bandage; or they may be treated by moulded 
binder's board or felt splints; the plaster-of-Paris dressing 
may also be used in these cases. The time required for union 
in fracture of the metatarsal bones is from three to four weeks. 

Fractures of the Phalanges of the Toes. — These fractures 
are often compound and attended with so much laceration 
of the soft parts that immediate amputation is required; 
when, however, the fractures are simple, or in compound 
fractures where amputation is not required, the dressing 
consists in applying a plantar splint of wood, wire or binders' 
board, extending beyond the toes and securing it in position 
by the turns of a roller bandage. When a single toe only is 
broken, a moulded splint of gutta-percha or binders' board 
may be applied, and a portion of the splint should extend 
some distance upon the sole of the foot, to fix the proximal 
joint, and also to give the toe a firm point of fixation; the 
moulded splint should be held in position by a narrow roller 
bandage or by strips of adhesive plaster. The time required 
for union in fractures of the phalanges of the toes is about 
three weeks. 

COMPOUND OR OPEN FRACTURES. 

In the dressing of compound or open fractures the same 
dressings and splints which are generally used in the treat- 
ment of simple or closed fractures may be employed; the 
wound in the soft parts requires a special dressing, and this 
should be so arranged as to secure free drainage and promote 
its prompt healing. In some cases of compound fracture the 
treatment of the injuries of the soft parts demands attention 
first, and in such cases the injury to the bones is for a time 
disregarded, care being taken that the fragments are kept 



520 



FRACTURES 



quiet, so as to prevent further damage to the soft parts until 
the wound is in such a condition that the proper manipulation 
to reduce the displacement and fix the fragments by splints 
and suitable dressings may be undertaken without interfering 
with the repair of the wound. 

Treatment.— In the dressing of compound or open fractures 
the skin surrounding the wound should first be carefully 
cleansed or painted with tincture of iodine, and the wound 
next be thoroughly irrigated with a 1 : 2000 bichloride solu- 
tion, and any foreign bodies or loose fragments of bone 
removed; if there is hemorrhage, it should be controlled by 
securing the bleeding vessels with ligatures; free venous ooz- 
ing may be controlled by gauze packing. The reduction 

Fig. 344. 




Lane's plates. 



of the displacement should next be accomplished by making 
extension and by manipulation; if the fragments project 
from the wound before this can be satisfactorily accomplished, 
it may be necessary to enlarge the wound and to resect one 
or both ends of the fractured bones, and in some cases it may 
be necessary to drill the ends of the fragments and introduce 
a strong wire or catgut suture, or a metallic nail, screw, or 
silver plate, or Lane's plates (Figs. 344 and 345) to hold them 
their proper positions. If metallic bodies are used to 



in 



COMPOUND OR OPEN FRACTURES 



521 



secure fixation of the fragments, where it is possible they 
should not be placed over a subcutaneous portion of the bone 
to prevent subsequent injury or irritation. In oblique frac- 
tures a single wire may be employed, introduced as shown 
in Fig. 346; in transverse fractures two wire sutures may be 
applied, as shown in Fig. 347. After reduction of the dis- 
placement the wound should again be thoroughly irrigated 
with an antiseptic or normal salt solution, and after making 



Fig. 345. 




Lane's plates applied to oblique fracture of the tibia. 

provision for drainage by the introduction of a drainage tube 
or tubes, counter openings being made to secure free drainage 
if necessary, sterilized or antiseptic gauze dressings should be 
applied. Debridement of the wound and Carrel-Dakin 
treatment may also be satisfactorily used in these cases. 

The wound, if a small one, need not be closed with sutures; 
but if extensive, a few catgut, silk, or silkworm-gut sutures 
may be applied to bring the edges of the wound into apposi- 



522 



FRACTURES 



tion, care being taken to avoid making undue tension; if the 
soft parts have been much lacerated or contused, it is better 
to introduce no sutures. If the limb is much swollen and the 
wound is a small one, free division of the deep fascia to relieve 
tension and secure drainage is often followed by good results. 
A final irrigation of the wound through the drainage tube is 
next made, and the wound is covered by a sterilized gauze 
dressing and a number of layers of sterilized cotton, the 
whole dressing being held in position by a gauze bandage 
applied with moderate firmness. 



Fig. 346. 



Fig. 347. 





Oblique fracture fixed by single 
wire suture. 



Transverse fracture fixed by two 
wire sutures. 



The reduction of the fragments and the dressing of the 
wound having been accomplished as described, the splints 
appropriate for a similar fracture, if it were a simple or closed 
one, are next applied. If the surgeon has been able to render 
the wound aseptic, and has applied an antiseptic dressing, 
the compound fracture is often soon converted into a simple 
one by the prompt healing of the wound, and the patient may 
exhibit no more constitutional disturbance than he would 
have with a similar simple or closed fracture. The redressing 
of a compound fracture dressed in this way need not be made 
for a week or ten days, unless there is a rise in the patient's 
temperature or the dressings become soaked with discharges 
from the wound, or they become uncomfortable to the patient 



COMPOUND OR OPEN FRACTURES 



523 



by reason of swelling of the soft parts in the region of the 
wound. When redressing of the fracture becomes necessary 
the dressings are removed, and the drainage tubes may also 
be removed if no longer needed; the wound being redressed 
with an antiseptic or aseptic dressing, the splints are reapplied 
and, after the wound is healed, the subsequent dressing of the 
fracture should be the same as that of a simple fracture. 
The time required for union in a compound fracture is usually 
much longer than in a corresponding simple fracture. 

Fig. 348. 




Fenestrated plaster dressing for compound fracture of the leg. 



Plaster-of-Paris Dressing.— This may be used as a primary 
dressing in compound fractures; the displacement being 
reduced and the wound dressed with an antiseptic gauze 
dressing, a plaster-of-Paris bandage is applied to the parts 
so as to firmly fix the fragments; the joints on either side 
of the fracture should be fixed by the bandage, and the parts 
should be held in position until the plaster has set firmly. 
After the plaster has become firm a fenestrum should be 
made over the position of the wound, so that it may be 
inspected or dressed through this when necessary (Fig. 348) . 



524 FRACTURES 

The ends of a piece of stout wire, bent into a semicircle, may 
be incorporated in the turns of the plaster bandage above 
and below the position of the fenestrum, to give it additional 
strength after the removal of a portion of the bandage to 
make the fenestrum. 

If the plaster-of-Paris dressing is applied as a primary 
dressing in compound fractures, the case should be carefully 
watched for a few days, and if much swelling occurs at the 
seat of fracture its removal and renewal^ are indicated; 
profuse discharge of serum may also soak the dressings and 
bandage, so that its renewal is necessitated. Some surgeons, 
therefore, prefer to defer the application of the plaster-of- 
Paris dressing in compound fractures for a few weeks until 
the swelling has diminished and the wound is nearly or quite 
healed ; the wound being covered with an antiseptic dressing, 
the plaster bandage is applied, and a fenestrum is made over 
the position of the wound if required. 

Binders' Board or Felt Splints.— These may also be employed 
in the dressing of compound fractures, being moulded to the 
parts after an antiseptic dressing has been applied to the 
wound, and held in position by the turns of a roller bandage. 

The principal advantage in the use of these splints is the 
ease with which they can be removed and reapplied if frequent 
dressings of the fracture are necessary for any reason. They 
may be used during the entire course of treatment; or, after 
a few weeks, when the swelling has diminished at the seat of 
fracture and the wound is well advanced toward repair, they 
may be discarded and a plaster-of-Paris dressing substituted. 
In compound fractures of the bones of the leg, after reducing 
the displacement and applying an antiseptic dressing to the 
wound, I usually apply moulded binders' board splints to 
either side of the leg, including the foot, and place the leg in 
a fracture-box for additional security. In a week or ten days 
I discard the binders' board splints and apply a plaster-of- 
Paris dressing. 

UNUNITED FRACTURE. 

This condition usually arises from local causes, such as 
imperfect coaptation of the fragments, the interposition of 



UNUNITED FRACTURES 



525 



muscular tissue, fascia, a tendon, or nerve, or a portion of 
devitalized bone between the fragments. The ends of the 
bones may be rounded, or may be united by fibrous tissue, or 
there may be an attempt at the formation of a false joint, the 
end of one fragment being rounded off and the other cupped 
to receive it. 

In cases of fracture in which union has not occurred at the 
usual time care should be taken to see that fixation of the 
fragments is as complete as possible, and in addition to the 



Fig. 349. 





Fragments in ununited fracture 
secured by silver wire. 



Fragments in ununited fracture 
secured by silver splint. 



retention of the fixation dressings a systematic use of Bier's 
hyperemic treatment should be instituted, as good results 
have often been obtained by its employment. 

Treatment.— This consists in exposing the ends of the bones 
by incision, with full antiseptic precautions, and removing 
the ends of the bones to secure a healthy surface, and then 
fixing the bones securely together by drilling them and 
introducing one or more heavy silver-wire sutures (Fig. 349). 



526 FRACTURES 

A dental engine equipped with a circular saw and drills will 
be found a most useful instrument in this work. In some 
cases the shape of the fragments is such that they can be 
sawed so as to form a mortise, and the bones can then be fixed 
by the introduction of one or more steel or silver screws. 
Another method of fixation is by a steel or silver splint 
(Fig. 350), a Lane's plate secured to the fragments by iron 
or silver screws. After the fixation of the bones has been 
accomplished, metal bands, and splints secured by screws, 
the wound should be closed and an antiseptic dressing 
applied; additional fixation is furnished by the application 
of a plaster-of-Paris dressing. 

Bone Transplantation in Ununited Fracture. — This pro- 
cedure has been practised in the treatment of ununited 
fractures. The ends of the bone are prepared as previously 
described, and a section of bone 1J to 2 inches in length and 
from \ to i of an inch in width is removed from the anterior 
edge of the tibia, the periosteum being retained only if the 
graft is to be used to span a gap, not when it is to be used as 
an intermedullary peg. This fragment is introduced into the 
medullary cavity of the fragments to act as a dowel. It may 
be necessary to ream out cavities in the bone tissues to make 
spaces for the bone graft or dowel. A portion of the upper 
surface of a rib may be used as the graft. It is important 
that the bone graft be removed from the same individual. 
The bone graft furnishes some fixation, but if additional fixa- 
tion is required, wire sutures or plates may be employed. 
The subsequent dressing is similar to that employed after 
other means of fixation of the fragments. 

Albee's Method.— Albee has demonstrated that a properly 
prepared and applied bone graft will stimulate the autogenous 
production of bone. He has devised an electric motor which 
is equipped with circular saws, twin saws, drills, reamers and 
lathe to fashion dowels from pieces of bone. 

The technic for ununited fractures is as follows: The 
ends of the bone are exposed by incision, the fibrous union 
is cut away and the ends of the bone are removed by a saw to 
obtain a healthy bone surface and the sclerosed tissue is 
removed from the medullary cavity. If there is over-riding 



COMPOUND OR OPEN FRACTURES 527 

of the fragments this is overcome by traction. If there is 
sufficient room to make a sliding bone insert, the twin saw 
is applied and a graft of sufficient length is cut from the 
cortex of the bone. The saw is next applied to the other 
fragment, a sufficient amount of bone is removed to receive 
the insert. Holes are next drilled through the cortex on each 
side of the grooves and after sliding the insert into its 
proper position it is secured by passing sutures of kangaroo 
tendon or chromicized catgut through the holes and securing 
them over the graft by tying. 

If an isolated bone graft is to be used, the tibia of the 
patient is exposed and a graft of sufficient width and length 
is removed and secured in the groove prepared for it by 
sutures. 

If an intermedullary graft is desired a doWel of sufficient 
length and thickness is made from a portion of bone taken 
from the tibia, and fitted into the previously prepared 
cavities in the fragment. 

Deformed Union. — Union in fractures may occur with more 
or less deformity in spite of careful treatment. If the 
deformity does not cause loss of function, surgical interference 
for its correction is not absolutely necessary. If, however, 
impairment of function is marked, its correction should be 
undertaken. Deformity in fractures of from four to six 
weeks' standing may be corrected by manipulation under 
anesthesia. To accomplish this the bone is refractured. In 
cases of longer standing, it may be corrected by osteotomy 
in suitable cases, or by exposing the seat of fracture and 
cutting away the callus so as to expose the ends of the frag- 
ments. These should then be prepared and secured in the 
corrected position by wire sutures or plates, a fixation dressing 
of plaster of Paris being subsequently applied. 



PART V. 
DISLOCATIONS 



Dislocation. — This consists in displacement of the articu- 
lar surfaces of the bones which enter into the formation of a 
joint. Dislocations may be complete, partial, simple, com- 
pound, and complicated, and they are also known as habitual, 
recent, and old dislocations. 

Complete Dislocation.— This is a dislocation in which no 
portions of the articular surfaces of the bones remain in 
contact with each other. 

Partial Dislocation.— This is a dislocation in which portions 
of the articular surfaces of the bones still remain in contact 
with each other. 

Simple Dislocation.— This is a dislocation in which there 
exists displacement in the relation of the articular surfaces 
of the bones with little injury to the soft parts adjacent to 
the joint, and the displaced ends of the bones do not com- 
municate with the air by a wound in the soft parts. 

Compound Dislocation.— This is a dislocation in which there 
exists displacement of the articular surfaces of the bones 
which communicate with the air through a wound in the soft 
parts. 

Complicated Dislocation.— This is a dislocation in which, 
in addition to the displacement of the articular surfaces of 
the bones, there exists a fracture, or a laceration of important 
bloodvessels, nerves, or muscles in connection with the 
dislocation. 

Habitual Dislocation.— This consists in a dislocation which 
constantly recurs upon slight provocation, and is usually 
due to a relaxed condition of the ligaments of the joint. 
34 



530 DISLOCATIONS 

Recent Dislocation.— This is a dislocation in which the 
displacement of the articulating surfaces of the bones has 
existed for such a period that time has not been afforded 
for inflammatory changes to take place in the articular 
surfaces of the bones or in the adjacent tissues which would 
seriously interfere with their reduction. 

Old Dislocation.— This is a dislocation in which the dis- 
placement of the articulating surfaces of the bones has existed 
for some time; in this variety of dislocation the displaced 
bones often form firm adhesions to the surrounding tissues, 
and the articulating surfaces often undergo changes. 

Treatment of Dislocations. — The first • indication in the 
treatment of dislocations is to return the displaced articular 
surfaces of the bones to their normal position, and to retain 
them in this position by the use of suitable dressings. The 
return of the articular surfaces of the bones to their normal 
position, or the reduction of the dislocation, is accomplished 
by manipulation, extension, and counter-extension. The 
reduction of dislocations should be attempted as soon as 
possible after they have occurred. 

The principal obstacles to . the reduction of dislocations 
are muscular resistance and the anatomical peculiarities of 
the joints. The former is best overcome by the use of an 
anesthetic given to the point where complete muscular relax- 
ation is produced. The resistance offered by the changed 
relations of the articular surfaces and the ligaments is to be 
overcome by the surgeon making such manipulations, founded 
upon his knowledge of the anatomy of the parts, as will 
make the ligaments, muscles, and bones assist in the reduc- 
tion of the dislocation. 

In recent dislocations, by the use of extension and manipu- 
lation, especially if an anesthetic be employed, the reduction 
is usually accomplished without the use of much force; but 
in old dislocations, where absolute muscular shortening has 
taken place, the use of extending bands is often required, and 
in securing these bands to the limb the clove-hitch knot is 
useful (Fig. 351). 

The treatment of dislocations after reduction consists in 
in placing the joint at complete rest by the application of 



DISLOCATIONS OF THE VERTEBRAE 531 

suitable splints and bandages, and in treating any inflam- 
matory complications, if they arise, by the application of 
evaporating lotions, and in a week or two, after the injured 
ligaments have been repaired, passive -motion should be 
resorted to for restoring the function of the joint. 

Fig. 351. 



Clove-hitch knot applied. 

SPECIAL DISLOCATIONS. 

Dislocations of the Vertebras. — Dislocations of the lumbar 
and dorsal vertebra, as simple dislocations, are extremely rare 
accidents; they are occasionally met with, but are more often 
associated with fractures of the vertebras in these regions. 
Uncomplicated dislocations of the cervical vertebrae are more 
common. The treatment of dislocations of the vertebrae, 
whether complicated with fracture or not, consists in attempt- 
ing reduction by making extension and counter-extension 
with manipulation, and by this means, in many cases, the 
luxations may be reduced. If, however, the efforts at reduc- 
tion are unsuccessful, permanent extension should be applied 
by means of a weight extension apparatus from both legs and 
from the shoulders and head. The after-treatment consists 
in keeping the patient at rest upon his back in bed upon a 
firm mattress, and if the cervical vertebrae have been involved, 
the head and neck should be supported by short sand bags; 
and in case of the vertebrae below this point, the application 
of a plaster-of-Paris jacket may be used to give support and 
fixation to the part. The general management of the case 



532 



DISLOCATIONS 



as regards complications is similar to that in cases of fracture 
of the vertebra? . 

Dislocations of the Coccyx. — These are reduced by manipu- 
lations with the finger in the rectum and external manipula- 
tion at the same time. The only after-treatment required 
is rest in bed for a few days and the administration of opium 
to keep the bowels quiet. 

Fig. 352. 




Bilateral dislocation of the lower jaw. 



Dislocations of the Lower Jaw. — These dislocations may 
consist in the displacement of one or both condyles of the 
lower jaw from the glenoid fossae, constituting the unilateral 
or bilateral dislocation of the jaw; the latter is the more 
common form of dislocation of the jaw met with, and the 
deformity resulting is shown in Fig. 352. 

The reduction of a dislocation of the lower jaw is accom- 
plished as follows: The surgeon placing his thumbs, well 
protected by strips of bandage or a towel, on the molar 
teeth or behind them, presses the angles of the jaw downward 



DISLOCATIONS OF THE STERNUM 533 

while he elevates the chin with his fingers, and by this 
manipulation the condyles of the jaw usually slip back into 
place with a snap (Fig. 353) . After reduction of the disloca- 
tion the jaw should be fixed for a week or ten days by the 
application of a Barton's bandage or a four-tailed sling. 

Fig. 353. 




Method of reducing dislocation of the lower jaw. 

Dislocation of the Hyoid Bone. — A few cases of dislocation 
of the hyoid bone have been recorded; the treatment consists 
in throwing back the head as far as possible, to place the 
muscles of the neck upon the stretch, depressing the lower 
jaw, and pressing the luxated bone into position. 

Dislocations of the Ribs and Costal Cartilages. — The ribs 
may be dislocated at their vertebral articulations or at the 
junction with the costal cartilages, or the cartilages may be 
separated from the sternum. These injuries result from the 
application of great force, and are often fatal from associated 
injuries of the thoracic viscera. The treatment of these dis- 
locations consists in reducing the displacement by manipula- 
tion and pressure, and then in fixing the chest to secure 
immobility of the ribs by strapping the affected side w T ith 
strips of adhesive plaster, the same dressing being applied 
as in cases of fracture of the ribs, the dressing being retained 
for three or four weeks. 

Dislocations of the Sternum. — Dislocation or diastasis of 
the sternum may occur at the junction of the manubrium and 
the gladiolus or at the junction of the ensiform cartilage and 



534 DISLOCATIONS 

the gladiolus. The reduction is effected by extension of the 
chest by bending the dorsal spine over a firm cushion placed 
under the back and by pressure upon the projecting bone; 
when the displaced bone has been reduced, a compress 
should be placed over the seat of injury, and held in place 
by broad strips of adhesive plaster, or by a bandage to keep 
the parts at rest. The dressing should be retained for three 
or four weeks. 

In the few examples of dislocation of the ensiform cartilage 
which have been reported, the displacement of the cartilage 
has in some cases given rise to persistent vomiting, which 
was relieved by reduction of the displacement; it is, however, 
almost impossible to keep the bone in place after reduction 
and excision of the displaced cartilage is indicated. 

Dislocations of the Pelvis. — Dislocation or diastasis of the 
bones of the pelvis may occur at the pubic or sacro-iliac 
symphyses. They are generally serious injuries, as they are 
apt to be complicated by lesions of the pelvic viscera. 

The reduction of these dislocations is effected by pressure 
and manipulation, and after reduction the parts should be 
supported by a compress held in place by a stout binder or by 
broad strips of adhesive plaster, the patient being kept quiet 
in bed and the pelvis being supported by means of sand bags. 
The dressings should be retained for from four to six weeks. 

Dislocations of the Clavicle.— Dislocations of the clavicle 
may occur either at the sternal or acromial end; the latter 
injury some writers describe as a dislocation of the scapula, 
following the general rule that the distal bone is the one 
dislocated. 

Dislocations of the Sternal End of the Clavicle. —These may 
occur in a forward, backward, or upward direction, and the 
displacement is generally well marked (Fig. 354). The re- 
duction of this dislocation is effected by placing the knee 
against the spine, and drawing the shoulders outward and 
backward and pressing the displaced end of the clavicle into 
place. The reduction is generally easy, but it is often 
difficult to keep the end of the bone in its proper position. 
To accomplish this, a compress should be placed over the 
end of the bone, and this should be secured in place by broad 



DISLOCATIONS OF THE CLAVICLE 



535 



strips of adhesive plaster; the shoulders should be brought 
well backward and secured by a posterior figure-of-eight 
bandage of the chest, and the arm of the injured side should 
be fastened to the side of the chest by spiral turns of a 
bandage. In some cases, in addition to the compress over the 
end of the bone, securing the arm of the injured side in the 
Velpeau position will be found all that is necessary to retain 
the bone in position. 



Fig. 354. 



Fig. 355. 




Dislocation of sternal end of 
clavicle forward. 




Dislocation of clavicle at 
acromial end. 



Dislocation of the Acromial End of the Clavicle. —This may 
be upward, downward, or backward (Fig. 355). The re- 
duction is effected by manipulation of the arm and scapula 
and by pressure over the displaced end of the clavicle. The 
displacement is usually reduced without much trouble, but 
it is often a matter of difficulty to keep the end of the bone 
in its proper place. The dressing consists in placing a com- 
press over the acromial end of the clavicle and holding it in 
place by broad strips of adhesive plaster; the arm should at 
the same time be fixed in the Velpeau position. 

Stimson's dressing consists in applying a long strip of 
adhesive plaster 3 inches wide, the center being placed over 
the flexed elbow and its end carried up in front of and behind 
the arm, crossing over the end of the clavicle and being 
secured on the front and back of the chest, respectively, while 



536 DISLOCATIONS 

the bone is held in place by pressure upon the clavicle and 
the elbow. For additional security, the forearm may be sup- 
ported in a sling and the arm bound to the side of the chest. 

The dressings after reduction of dislocations of the clavicle 
should be kept in place for at least three weeks. Although 
in many cases a certain amount of deformity persists, the 
disability resulting from the injury is not often marked. 

Persistent deformity with disability in either sternal or 
acromial dislocations of the clavicle may require fixation by 
suture. 

Dislocations of the Scapula. — Dislocation of the acromion 
process of the scapula from the outer end of the clavicle, 
which has been described under dislocations of the acromial 
end of the clavicle, is classed by some writers as a scapular 
dislocation. 

Dislocation of the Inferior Angle of the Scapula.— The 
displacement of the inferior angle of the scapula from under 
the latissimus dorsi muscle is due to relaxation of this muscle 
and of the serratus magnus, and is sometimes described as a 
dislocation of the inferior angle of the scapula. The reduction 
of this deformity consists in the employment of manipulation 
and pressure to overcome the displacement, and the use of a 
compress held in place by broad strips of adhesive plaster to 
secure the bone in its proper position. 

Dislocations of the Shoulder. — The head of the humerus 
may be dislocated downward, forward, or backward. 

Subglenoid Dislocation of the Head of the Humerus.— In 
this variety of dislocation the head of the bone rests in the 
axilla (Fig. 356). 

Subcoracoid Dislocation of the Head of the Humerus.— In 
this variety of dislocation the head of the humerus rests 
beneath the coracoid process of the scapula (Fig. 357) . 

Subclavicular Dislocation of the Head of the Humerus.— This 
may be considered an aggravated form of the latter variety 
of dislocation; the head of the humerus in this dislocation 
rests beneath the clavicle. 

Subspinous Dislocation of the Head of the Humerus.— In this 
variety of dislocation the head of the humerus rests beneath 
the spine of the scapula (Fig. 358) . 



DISLOCATIONS OF THE HUMERUS 



537 



Reduction of dislocations of the humerus is effected by 
manipulation, by extension and counter-extension, and by 
a combination of these methods. 



Fig. 356. 



Fig. 357. 





Subglenoid dislocation of the head 
of the humerus. 



Subcoracoid dislocation of the head 
of the humerus. 



Fig. 358. 




Subspinous dislocation of the head of the humerus. 



538 DISLOCATIONS 

Manipulation in the reduction of subglenoid dislocation 
of the humerus is practised with the patient in the recumbent 
posture by first flexing the forearm upon the arm to relax 
the long head of the biceps muscle; the elbow is next seized 
and abducted so as to bring it to the side of the patient's 
head, thus relaxing the deltoid and supraspinatus muscles; 
the surgeon or an assistant next places his hand upon the 
head of the humerus in the axilla, and, as the arm is drawn 
outward to a right angle with the body by the other hand, he 
pushed the head of the bone into the glenoid cavity. 

In the reduction of subcoracoid and subclavicular disloca- 
tions the manipulations are the same, except that the arm 
is to be rotated outward before being carried downward. 

In the reduction of subspinous dislocations, after the arm 
has been abducted, it should be rotated inward and direct 
pressure made upon the head of the bone as the arm is 
abducted. 

Reduction may also be effected by extension and counter- 
extension, as in Cooper's method, where extension is made 
from the arm downward and counter-extension is made by 
the heel in the axilla. This method is not to be recom- 
mended, on account of the damage which may occur to the 
axillary nerves and vessels. 

Kocher's Method.— Place the patient in the sitting posture 
and flex the elbow to a right angle, at the same time pressing 
the arm against the chest; the flexed forearm is then turned 
as far as possible from the trunk by rotating the humerus 
outward until it occupies a position parallel with the trans- 
verse plane of the body (Fig. 359). While the external 
rotation is being maintained the elbow is slowly carried 
upward along the anterior border of the chest until it reaches 
a point opposite the ensiform cartilage (Fig. 360) ; the forearm 
is then quickly rotated inward until the hand touches the 
opposite shoulder and the elbow is lowered (Fig. 361). 

Mothe's Method.— Reduction by this method may also be 
accomplished by extension made upward, the scapula being 
fixed by the foot or hand placed over the acromion process 
(Fig. 362). 

After reduction of dislocations of the head of the humerus 



Fig. 359. 




Kocher's method of reduction: first position. 
Fig. 360. 




Kocher's method: second position. 



540 



DISLOCATIONS 



the arm should be bound to the side of the body by the turns 
of a spiral bandage of the chest, or should be held against 



Fig. 361. 




f 

Kocher's method: third position. 



Fig. 362. 




Reduction of dislocation of the humerus by extension upward. 



DISLOCATIONS OF THE ELBOW 



541 



the side by the application of a Velpeau bandage; this 
dressing should be removed at intervals of a few days, and 
after ten days or two weeks all dressings should be dispensed 
with, passive motion should be employed, and the patient 
allowed to move the arm. 



Fig. 363. 




Dislocation of both bones of the forearm backward. 



Dislocations of the Elbow. — Dislocations of the bones of 
the forearm at the elbow may be either backward, forward, 
or lateral. The backward dislocation is the most common 
form (Fig. 363). 

Fig. 364. 




Mechanism of reduction of posterior dislocation of elbow by aid of the knee. 

(Ashhurst.) 

The reduction of backward dislocations is effected by mak- 
ing traction upon the forearm and at the same time making 



542 



DISLOCATIONS 



pressure upon the lower end of the humerus as the forearm 
is flexed upon the arm. 

Or the reduction may be accomplished by bending the arm 
slowly and forcibly over the knee placed upon the inner 
surface of the elbows, so as to press upon the radius and ulna, 
separating them from the humerus and freeing the coronoid 
process from its abnormal position (Fig. 364). 

Lateral dislocations of the bones of the forearm at the elbow 
may be external or internal and are usually due to direct 
force. External lateral dislocation is generally incomplete, 





Fig. 365. 








1 

1 




d0* 


^■9 


1 



Internal lateral dislocation of ulna and radius. (Ashhurst.) 



and complicated by fracture of the external condyle of the 
humerus, and extensive rupture of the internal lateral liga- 
ment. Internal lateral dislocation is not so apt to be asso- 
ciated with fracture. In both of these dislocations the bony 
processes are easily palpable and the deformity is extreme. 
These dislocations are reduced by making extension from 
the forearm, and at the same time making direct pressure 
on the displaced bones and counter-pressure on the lower 
end of the humerus. 

Reduction is usually not difficult, but if associated with 
fracture of the condyle it is sometimes difficult to maintain. 



DISLOCATIONS OF THE RADIUS 543 

Hyperflexion of the elbow is the best position in which to dress 
this injury. 

Forward dislocations of the bones of the forearm at the 
elbow are reduced by making forced flexion at the elbow, 
together with extension and counter-extension, or by making 
forced extension of the forearm at the elbow, pressing the 
humerus backward, and suddenly flexing the forearm. 

The dressing, after the reduction of dislocations at the 
elbow, consists in the application of a well-padded anterior 
right-angled or slightly obtuse-angled splint, to keep the 
forearm in a flexed position— the dressing being practically 

Fig. 366. 





/ 




/ 


s_„ 


* '• i *3^ : <■ 



Dressing after reduction of dislocation of the elbow. 

the same as that for fractures of the lower end of the humerus, 
with an anterior angular splint (Fig. 366). This dressing 
should be retained for two or three weeks, being removed at 
intervals of several days; after the removal of the splint 
passive motion should be practised, to prevent stiffness of the 
elbow-joint. 

Dislocations of the Head of the Radius. — The head of 
the radius may be displaced forward, outward, or backward, 
the forward dislocation being the most frequent. In this 
dislocation the head of the radius slips out of the grasp of the 
orbicular ligament and is displaced forward by the action of 
the biceps muscle. This injury is often associated with a 



544 DISLOCATIONS 

fracture of the upper end of the ulna. The reduction of these 
dislocations is effected by making extension from the forearm 
and counter-extension from the lower end of the humerus, 
and at the same time the head of the bone is pressed into its 
proper position. The dressing after reduction of the dis- 
placement consists in the application of a compress over the 
head of the bone, and the arm and forearm should be placed 
upon a well-padded anterior angular splint, which is secured 
by a roller bandage. The dressing is similar to that employed 
after reduction of dislocations of the bones of the forearm at 
the elbow. Difficulty is sometimes experienced in keeping 
the head of the bone in position after reduction, so that the 
use of a compress in addition to the use of the splint is often 
required. The arm should be kept upon the splint for three 
weeks, being redressed at intervals. Subluxation of the head 
of the radius also known as pulled elbow occurs only in children 
and results from vertical traction upon the forearm in lifting 
the child by one arm. The head of the radius is not com- 
pletely dislocated but displaced slightly forward. Tender- 
ness in front of the elbow and some loss of function are the 
principal symptoms of this injury. I have always been able 
to reduce this displacement by pressure over the head of the 
radius with the thumb with pronation and supination of the 
arm at the same time. The elbow should be kept at rest on 
an anterior angular splint for a week. 

Dislocation of the Upper End of the Ulna. — The upper 
end of the ulna may be displaced backward, the olecranon 
projecting beyond the condyles of the humerus, while the 
head of the radius occupies its normal position. 

The reduction of this displacement is effected in the same 
manner as that of both bones of the forearm backward, and 
the dressing after reduction is similar to that employed when 
both bones have been displaced. 

Dislocations of the Wrist. — Dislocations of the carpus from 
the bones of the forearm are rare; may he forward (Fig. 367) 
or backward (Fig. 368). The reduction in either variety of 
displacement is effected by extension from the hand and 
by pressure. After reduction of the displacement, which 
does not tend to recur, the hand and the forearm should be 



DISLOCATIONS OF BONES OF CARPUS 



545 



placed upon a well-padded straight splint applied to the 
palmar surface of the hand and forearm. The splint should 
be retained for ten days or two weeks. 



Fig. 367. 




Dislocation of the carpus forward. 

The lower end of the ulna may be dislocated from the 
radius forward, backward, or inward. The reduction of these 
displacements is effected by fixing the radius and pressing the 
ulna back into place. The dressing after reduction consists 
in placing the wrist-joint at rest by the application of well- 
padded anterior and posterior straight splints. The splints 
should be retained for three or four weeks, dressings being 
made at intervals of two or three days. 

Fig. 368. 




Dislocation of the carpus backward. 



Dislocations of the Bones of the Carpus. — Displacement of 
the individual bones of the carpus occasionally takes place, 
the semilunar may be displaced forward and the os magnum 
and scaphoid backward, these being the bones most usually 
displaced, although other bones of the carpus are sometimes 
dislocated. Reduction which is not always possible is effected 
35 



546 DISLOCATIONS 

by means of extension and pressure, and the part should 
afterward be dressed with a palmar splint and compresses. 
If it is found impossible to reduce the displaced bone, it 
should be excised. 

Dislocations of the Metacarpal Bones. — The metacarpal 
bones may be dislocated from the carpus; the bones most 
commonly displaced are those of the thumb and of the index 
and middle fingers; the latter are usually displaced backward, 
while the metacarpal bone of the thumb may go either back- 
ward or forward. 

Reduction is effected by extension and pressure. The 
dressing after reduction consists in the application of a palmar 
splint to the hand and forearm and a compress over the 

Fig. 369. 




Backward dislocation of phalanx. Reduction by extension. 

displaced bone. The dressings should be retained for two 
weeks. 

Dislocations of the Fingers. — Dislocations of the phalanges 
of the fingers usually take place at the metacarpo-phalangeal 
junction, but sometimes occur at the interphalangeal joints. 
The reduction is usually easily effected by extension (Fig. 369), 
or by pushing the phalanx back until it stands perpendicu- 
larly upon the metacarpal bone, when by strong pressure upon 
its base from behind, forward, it is readily carried by flexion 
into its natural position. 

Where difficulty is experienced in making extension in the 
reduction of these dislocations, the ingenious apparatus of 
the late Dr. Levis (Fig. 370), or the "Indian puzzle" appara- 
tus (Fig. 371), may be employed with success. 



DISLOCATIONS OF THE FINGERS 



547 



Dislocations of the proximal phalanx of the thumb backward 
may result from a fall upon the thumb causing violent hyper- 

Fig. 370. 




Levis' apparatus for dislocation of the phalanges applied. 

extension. The deformity is quite characteristic (Fig. 372). 
The head of the metacarpal bone is buttonholed through the 

Fig. 371. 




Extension by Indian puzzle. 



anterior ligament, and the tendons of the short flexor muscles 
of the thumb and the lateral ligaments fit tightly about the 



Fig. 372. 




Dislocation of proximal phalanx of thumb backward. 

neck of the metacarpal bone. The interposition of the 
external sesamoid bone is considered by some surgeons to be 
the cause of difficulty in the reduction of this displacement. 



548 DISLOCATIONS 

The reduction of this dislocation is often very difficult. 
It is effected by firmly pressing the metacarpal bone of the 
thumb strongly toward the palm of the hand, to relax the 
two portions of the short flexor muscle. The thumb is next 
extended upon the wrist until its tip points to the elbow. 
An assistant next places his finger behind the proximal 
phalanx to prevent its slipping backward, and by bringing 
the thumb down to the flexed position the bone slips into 
place. It sometimes happens that all efforts at reduction 
fail, and in such cases it may be necessary to divide one 
head of the short flexor muscle and the lateral ligament 
through a wound on the radial border of the flexor surface 
over the head of the metacarpal bone of the thumb before 
the displacement can be reduced. 

The dressing of dislocations of the phalanges after reduc- 
tion consists in the application of splints of wood, or moulded 
splints of binders' board, or gutta-percha, to fix the joint, 
which should be retained for ten days or two weeks. 

Dislocations of the Hip. — The head of the femur is most 
frequently dislocated backward, downward, or upward, 
although it may assume other positions in exceptional cases. 

This injury is a comparatively rare one, which generally 
results from indirect violence, the femur being forced beyond 
its normal range either in flexion and abduction, or in exten- 
sion and abduction, the head of the femur by leverage is 
forced out of the acetabulum. The prominent symptoms of 
posterior dislocations are immobility, shortening with flexion 
abduction and internal rotation at the hip. 

Posterior or Backward Dislocations of the Head of the Femur. 
—These are either backward and upward, when they are 
described as iliac or dorsal, the bone resting upon the dorsum 
of the ilium (Fig. 373) ; or the dislocation may be backward, 
the head of the bone resting upon the ischiatic notch; these 
are known as ischiatic dislocations, or dislocations of the 
femur, dorsal below the tendon (of the obturator internus), 
according to Bigelow (Fig. 374). 

The reduction of the posterior dislocations of the femur can 
generally be effected by manipulation. The patient being 
anesthetized and placed upon his back, the surgeon grasps 



DISLOCATIONS OF THE HIP 



549 



the leg at the ankle and knee, flexes the leg upon the thigh, 
and the thigh upon the pelvis in the position of adduction; 
he then abducts the limb and rotates it outward, bringing it 
in a broad sweep across the abdomen, and by bringing it 
down to its natural position the head of the bone will slip 
into the acetabulum (Fig. 375). 



Fig. 373. 



Fig. 374. 




^Xg^ 




Backward and upward disloca- 
tion of femur. 



Backward dislocation of femur. 



Kocher, in posterior dislocations, recommends the follow- 
ing manipulations: (1) The surgeon grasps the ankle of the 
injured limb with one hand and the front of the knee with the 
other and rotates the thigh inward to relax the capsule and 
lift the head of the bone from the posterior surface of the 
pelvis; (2) the thigh is next flexed to 90 degrees, preserving 



550 DISLOCATIONS 

the existing adduction and inward rotation; (3) traction is 
then made in the line of the femur, to make the capsule tense; 
(4) external rotation is then practised, which makes the 
posterior part of the capsule and Y-ligament tense, and 
returns the head of the bone to the acetabulum. 

Direct Method. — The patient being under anesthesia is 
placed upon the floor upon a firm mattress, and the pelvis 
being firmly fixed by an assistant, the surgeon places his arm 
under the flexed knee. The thigh is flexed to a right angle on 
the pelvis, bringing the head of the femur toward the lower 
part of the acetabulum. The knee is next flexed to a right 
angle and the arm is passed under this and upward traction is 



Reduction of backward dislocation of the femur. 

made; at the same time slight adduction, or the thigh may 
be gently rotated in and out. Under this manipulation the 
head of the bone usually slips into the acetabulum. This 
method I have found most satisfactory in all posterior 
displacements. 

Downward and Forward Dislocation of the Head of the Femur. 
— In this variety of dislocation the head of the bone rests 
upon the thyroid foramen; this form of displacement is 
sometimes spoken of as a thyroid dislocation (Fig. 376). 

The marked symptoms of this displacement are immobility, 
flexion, abduction and eversion and apparent lengthening of 
the limb. 



DISLOCATIONS OF THE HIP 
Fig. 376. 



551 




Downward and forward dislocation of femur. 



Fig. 377. 




Reduction of downward and forward dislocation of femur. 



552 DISLOCATIONS 

The reduction of downward and forward dislocations of the 
head of the femur is effected by flexing the leg and thigh and 
bringing the limb into a position of abduction; it is then 
adducted and rotated inward in a broad sweep across the 
abdomen and brought down to its natural position when the 
head of the bone slips into the acetabulum (Fig. 377). 

In making these manipulations the head of the bone some- 
times slips back upon the dorsum of the ilium, converting the 
downward dislocation into a posterior one; if this accident 
occurs the displacement should be reduced by making the 
manipulations appropriate for the reduction of the latter 
dislocation. 

Kocher, in the reduction of these dislocations, recommends 
the following manipulations: (1) The leg should be flexed 
upon the thigh and the thigh carried up to a right angle with 
the pelvis, maintaining abduction and external rotation, to 
relax the Y-ligament; (2) traction should next be made in 
the line of the shaft of the femur, to render the posterior part 
of the capsule tense; (3) outward rotation is then made, 
which, twisting the tense posterior portion of the capsule and 
the outer branch of the Y-ligament, brings the head of the 
bone upward and backward into the acetabulum. 

Forward and Upward Dislocation of the Head of the Femur. — 
In this variety of dislocation, which is very rare, the head 
of the bone rests upon the pubis; this form of displacement 
is also spoken of as a pubic dislocation (Fig. 378) . 

The reduction of forward and upward dislocations of the 
head of the femur is effected by much the same manipulation 
as is employed in the reduction of downward and forward 
dislocations, except that in the pubic dislocation the flexed 
limb should be carried across the sound thigh at a higher 
point. The thigh being flexed, the head of the bone is drawn 
down from the pubis; it is then semiabducted and rotated 
inward to disengage the bone completely. While rotating 
inward and drawing on the thigh the knee should be carried 
inward and downward to its place by the side of its fellow, 
and the head of the bone will usually slip into the acetabulum. 

Kocher, in the reduction of forward and upward disloca- 
tions of the femur, recommends: (1) Traction should first 



DISLOCATIONS OF THE FEMUR 



553 



Fig. 378. 



be made in the axis of the limb to bring the head of the bone 
over the brim of the pelvis; (2) pressure should next be made 
with the hand upon the head of the femur to prevent its 
passing upward during flexion of the thigh; (3) the thigh 
should next be flexed to less than a right angle to relax the 
Y-ligament; (4) inward rotation is next made which directs 
the head of the bone into the aceta- 
bulum. 

Anomalous Dislocations of the Head 
of the Femur. — These occasionally 
occur; the head of the bone may 
pass directly upward or downward 
between the sciatic notch and thy- 
roid foramen, or downward and 
backward on the body of the is- 
chium, or downward and backward 
into the lesser sciatic notch, or 
downward, inward and forward into 
the perineum. Central dislocation is 
occasionally seen in which the aceta- 
bulum is fractured and the head of 
the bone is driven into the pelvis. 
These anomalous displacements us- 
ually occur where there has been 
extensive laceration of the capsular 
ligament and Y-ligament. 

The treatment of cases after reduc- 
tion of dislocations of the head of 
the femur consists in keeping the 
patient at rest in bed upon his back; 
the limb should be kept at rest by 
sand bags applied to either side of 
the limb, or the knees should be 

tied together. If the joints are painful from the traumatism, 
extension should be applied for a few days which usually 
relieves the pain. The patient should be kept at rest for 
two weeks, and at the end of this time may be allowed to get 
out of bed and go about on crutches. 




Forward and upward disloca- 
tion of the femur. 



554 



DISLOCATIONS 



Fig. 379. 



Dislocations of the Patella. — The patella may be dislo- 
cated outward, inward or upward, or it may be rotated upon 
its own axis. The outward dislocation is the displacement 
most usually seen (Fig. 379). A downward displacement 
associated with a rupture of the quadriceps extensor tendon 
also may occur. 

Upward dislocation of the patella can only result from 
laceration of the ligamentum patellae, and the treatment in 

such cases is similar to that for 
fracture of the patella. 

The reduction of dislocations 
of the patella is effected by ex- 
tending the leg upon the thigh 
and flexing the thigh upon the 
pelvis, to relax the quadriceps 
femoris muscle, when the patella 
can usually be forced back into 
place by manipulation with the 
fingers; in some cases alternate 
flexion and extension of the leg 
will accomplish the same result. 
The dressing after reduction of 
the displacement consists in the 
application of a posterior straight 
splint or a moulded binders' board 
or felt splint to keep the joint at 
rest; the splint should be worn 
for a week or ten days. 

Dislocations of the Knee. — The 
head of the tibia maybe dislocated 
forward, backward or laterally; the 
latter dislocations are always incomplete, forward dislocation 
being the variety of displacement most commonly met with 
(Fig. 380). Dislocations of the knee are comparatively rare 
injuries and may be very serious when complicated by injuries 
of the popliteal vessels or nerves. 

The reduction of dislocations of the knee is effected by 
extension- and counter-extension with forced flexion of the 
knee with pressure, aided by rocking movements. The treat- 




Outward dislocation of the 
patella. 



DISLOCATION OF THE SEMILUNAR CARTILAGES 555 

ment of cases of dislocation of the knee after reduction con- 
sists in fixing the knee-joint by the application of a straight 
posterior splint or a moulded splint of binders' board. As 
there is usually marked swelling following these injuries from 
violence to the joint structures, the application of evaporating 
lotions for a few days will be found useful. As soon as the 
swelling has subsided the limb should be put up in a plaster- 
of-Paris dressing, and this should be retained for four weeks. 
Dislocation of the Semilunar Cartilages. — The displace- 
ment here consists in the slipping forward or backward and 
wedging of the semilunar cartilages between the femoral 
condyles and the tibia. The cartilage may be fractured and 
the anterior crucial ligament may also be ruptured. 

Fig. 380. 
Patella. 



External condyle of femur. 
Forward dislocation of the knee. 

Reduction of the displaced cartilages can usually be effected 
by hyperflexion of the knee, followed by sudden full exten- 
sion, or by alternately flexing and extending the joint. Exci- 
sion of the displaced cartilages is sometimes required in cases 
in which they cannot be reduced by manipulation. 

The dressing of these cases after reduction of the dis- 
placed cartilages consists in the application of a posterior 
straight splint or a plaster-of-Paris dressing to fix the knee- 
joint; the splint should be worn for three or four weeks, and 
if there is a tendency to redisplacement the patient should 
wear a brace, or a knee cap of leather or muslin to partially 
fix the joint, with compresses so arranged as to make pres- 
sure upon the edge of the joint. 



556 



DISLOCATIONS 



Dislocations of the Fibula. — Dislocations of the fibula may 
occur at either of its extremities, and the direction of the 
displacement may be forward, backward or outward; disloca- 
tion of the head or upper extremity of the fibula being the 
most common, although all are rare forms of displacement. 

The reduction of dislocations of the head of the fibula is 
effected by flexing the leg upon the thigh and making direct 
pressure and extension. Dislocations of the lower extremity 
of the fibula are reduced by manipulation and pressure. 
The dressing of cases after reduction of dislocations of the 
fibula consists in the application of a compress and moulded 
binders' board splint; the dressing should be retained for 
three or four weeks. 




Fig. 382. 




Dislocation of foot backward. 



Dislocation of foot inward. 



Dislocations of the Ankle. — Dislocations of the foot upon 
the bones of the leg result from separation of the articular 
surface of the astragalus from that of the tibia and fibula; 
the displacement may be forward, backward (Fig. 381) or 
lateral (Fig. 382), the latter variety being often associated 
with fractures of the malleoli. 

The reduction of dislocations of the ankle is effected by 
traction, combined with flexion and rotation of the ankle- 
joint, the leg being first flexed upon the thigh to relax the 



DISLOCATIONS OF THE TARSAL BONES 



557 



tendo Achillis, and in some cases the subcutaneous division 
of this tendon is required before the reduction can be satis- 
factorily accomplished. 

The dressing of dislocations of the ankle after reduction 
consists in the application of a fracture-box or of pasteboard 
splints to fix the ankle, care being taken to see that the foot 
is fixed at a right angle to the leg, and in the application of 
evaporating lotions for a few days; after the swelling has 
subsided a plaster-of-Paris dressing should be applied and 
retained for three or four weeks. 




Dislocation of astragalus outward. 



Dislocations of the Tarsal Bones. — The astragalus may be 
dislocated from the bones of the leg and from the other tarsal 
bones, being thrust forward, backward, outward (Fig. 383) or 
inward. The reduction of dislocations of the astragalus out- 
ward is effected by first flexing the leg upon the thigh and 
making extension from the foot and rotating it at the same 



558 DISLOCATIONS 

time, direct pressure being made upon the displaced bone; in 
some cases subcutaneous section of the tendo Achillis has 
assisted materially in the reduction of the displaced bone. 
Backward dislocation of the astragalus is usually irreducible; 
the patient, however, in many cases recovers with a useful 
foot. In cases of irreducible dislocations of the astragalus 
excision of the astragalus may ultimately be required. 

After the reduction of dislocations of the astragalus the 
foot and leg should be put at rest in a fracture-box, or by 
means of moulded splints of pasteboard or felt; evaporating 
lotions should also be employed over the region of the injury 
for a few days, and when the swelling has subsided a plaster- 
of-Paris dressing should be applied and retained for three or 
four weeks. 

Dislocations of the calcaneum and scaphoid upon the astraga- 
lus or of the calcaneum upon the astragalus and cuboid or upon 
the astragalus alone, of the scaphoid and cuboid upon the os calcis 
and astragalus or of the cuboid, scaphoid or cuneiform bones are 
occasionally met with. 

Their reduction is effected by traction and direct pressure, 
and after this has been accomplished the parts should be put 
at rest by the application of a splint and compresses. 

Dislocations of the Metatarsal Bones and Phalanges of 
the Toes. — These dislocations usually result from crushing 
forces which destroy the vitality of the soft parts so com- 
pletely that amputation is required. Their reduction in cases 
of simple or uncomplicated dislocations is effected by traction, 
manipulation and pressure. After reduction of the displace- 
ment the parts should be kept in position by the application 
of splints and bandages. 

Old Dislocations. — The reduction of old dislocations is 
attended with more difficulty and danger than that of recent 
dislocations, due to the permanent contraction and structural 
changes which occur in the muscles and to the adhesions 
which form between the displaced bone and the parts with 
which it is in contact. Some dislocations became "old" 
much sooner than others. It may be wise not to attempt to 
reduce a dislocation of some months' standing unless pain 
and disability are marked. The reduction of old dislocations 



COMPLICATED DISLOCATIONS 559 

may usually be accomplished by the manipulations appro- 
priate for recent dislocations of the same variety; but occa- 
sionally the use of more forcible extension is required, which 
is made by bands and pulleys. The first step in the reduc- 
tion of old dislocations consists in thoroughly breaking up 
the adhesions which have been formed between the displaced 
bone and the surrounding tissues; this has, in some cases, 
resulted in the laceration of muscles, nerves and bloodvessels 
and in fracture of the displaced bones or neighboring bones, 
so that the manipulations should be made with the least force 
that will accomplish the object desired. After the reduction 
of old dislocations difficulty is sometimes experienced in 
maintaining the bone in its proper place, due to the changes 
which have occurred in the articular surfaces. 

In such cases fixation of the bone in its normal position by 
a plaster-of-Paris dressing should be employed for some 
weeks, and after its removal passive motion should be 
practised. If the dislocation is found to be irreducible and 
the patient suffers from great pain and disability open opera- 
tion is advisable. This consists in exposing the displaced 
bone and dividing the soft tissues which interfere with 
reduction or in making a complete or incomplete excision of 
the joint. 

Compound Dislocations. — These are always grave injuries 
and amputations or excision may be required. With the 
modern methods of wound treatment, operative measures 
are not often required. The reduction is effected in the 
same manner as in simple dislocations of corresponding parts, 
the greatest care being taken to render the wound aseptic, 
and to keep it in this condition by the application of a full 
antiseptic dressing. After reducing the dislocation and 
dressing the wound some form of fixation splint should be 
applied to fix the joint until healing of the wound has 
occurred. 

Complicated Dislocations. — In dislocations complicated by 
fracture near the seat of displacement the displaced bone 
should, if possible, be first reduced, and this in many cases is 
a matter of great difficulty, as the fracture prevents the 
surgeon from using leverage otherwise present, in the reduc- 



560 DISLOCATIONS 

tion, and he has often to depend entirely upon pressure and 
manipulation to overcome the displacement. After reduc- 
tion of the dislocation the fracture should be reduced and 
dressed. 

Dislocation complicated by rupture of the main artery of 
the limb may require, after reduction of the displacement, 
exposure and ligation of the vessel or amputation of the limb. 
Rupture of an important nerve trunk complicating a disloca- 
tion may call for subsequent exposure and suturing of the 
divided nerve. 

Habitual, Pathological and Congenital Dislocations. — In 
the treatment of these varieties of dislocations after the 
reduction of the displacement by manipulation and pressure, 
much difficulty is often experienced in maintaining the 
reduction. To effect the latter object the use of splints and 
bandages is employed, and also the use of many ingenious 
forms of apparatus adapted to particular dislocations. Con- 
genital dislocations of the hip are now successfully treated by 
the method of Lorenz. Operative treatment, such as exci- 
sion of a portion of the capsule of the joint or ligaments, or 
operation upon the bone to increase the capacity of the joint 
may be practised. 

Tenotomy or myotomy is often required to prevent recur- 
rence of the deformity, and continuous extension is also of 
much value in the treatment of these displacements. 



PART VI. 
OPERATIONS 



AMPUTATIONS OF THE FINGERS AND METACARPAL 

BONES. 

The instruments required for amputation of the ringers 
toes and metacarpal or metatarsal bones are a scalpel (Fig. 

Fig. 384. 




Scalpel. 
Fig. 385. 




Small amputating saw. 
Fig. 386. 




Bone forceps, or cutting pliers. 

384), a metacarpal or small amputating saw (Fig. 385) and a 
pair of bone forceps or cutting pliers (Fig. 386) . 

In amputating the fingers or hand the surgeon should 
36 



562 



OPERATIONS 



exercise the utmost conservatism. If a portion of the hand 
with one or more fingers or parts of fingers can be preserved 
the member is much more useful than any artificial appliance. 
Amputations of the Fingers. — The fingers may be ampu- 
tated in the continuity of the phalanges or in their contiguity, 
and, as a rule, as it is important to save as much as possible 
of the finger the former method is generally to be employed 
instead of disarticulation at a higher point. The incision 
should be so planned that the cicatrix does not occupy the 
palmar surface; the larger flap should, therefore, be taken 

Fig. 387. 





Amputation of a finger by the long palmar flap. 



from the palmar aspect of the finger. In amputating the 
phalanges of the fingers in their continuity the circular method 
(Fig. 387) or a short dorsal flap and a long palmar flap may 
be employed. In disarticulating a phalanx it is best to enter 
the joint with a narrow knife from the dorsal side, and after 
having carried it through the joint, to cut a long palmar flap, 
keeping close to the bone (Fig. 387) . In locating the position 
of the phalangeal joints it is well to remember that the prom- 
inence of the knuckle when the finger is flexed is formed 
entirely of the head of the proximal and not of the base of 



AMPUTATIONS OF THE FINGERS 



563 



the distal phalanx (Fig. 388), and also that the folds on the 
palmar surface of the finger do not correspond exactly to 
the joints (Fig. 389). 

Amputation of the Finger through the Metacarpophalan- 
geal Articulation. — In this variety of amputation an incision 
is made from a point on the dorsal surface of the metacarpal 
bone \ inch above the articulation, which is carried through 
the interdigital web and back upon the palmar surface to a 
point \ inch above the flexor fold 
(Fig. 391). A similar incision be- 
ginning and ending at the same 
points is made upon the opposite 
side of the finger. The flaps are 
dissected back and the lateral liga- 
ments, tendons and remainder of 
the capsule are divided (Fig. 
390). The finger may also be 

Fig. 388. 



Fig. 389. 





Phalanges flexed. 



Guides to articulations of the fin- 
gers, a, head of metacarpal bone; 6, 
metacarpophalangeal articulation; c, 
relation of palmar fold to articulation; 
d, e, interphalangeal articulation; /, 
articulation of distal phalanx. 



amputated at the metacarpo-phalangeal joint by making an 
incision on one side and dissecting the flap back to the joint, 
then dividing the lateral ligament, opening the joint and 
carrying the knife across this, dividing the tendons and 
lateral ligament on the other side and cutting a flap from 
within outward. 

Removal of the head of the metacarpal bone if desired may 
be accomplished by the use of cutting pliers (Fig. 386) ; but, 



564 



OPERATIONS 



as a rule, this procedure is not to be recommended, for, 
although the deformity is lessened, the strength of the hand 
is diminished. 

In amputating the little and index fingers a full lateral flap 
may be cut on the free side, and an incision is next carried 
across the palmar surface to the angle of the web, and thence 
back to the joint, which is opened and the disarticulation 
effected (Fig. 391). The digital arteries are usually the only 
vessels requiring the use of ligatures. 



Fig. 390. 




Racket-shaped incision for amputation of the finger at the metacarpo-phalangeal 

joint. 

Amputations of the Metacarpal Bones. — In amputating 
the metacarpal bones it is advisable to leave the carpal ends 
of the bones to avoid opening the wrist- joint, except in the 
case of the first and fifth metacarpal bones, which do not 
communicate with the others and with the synovial sacs. 

The incisions for the removal of the metacarpal bones are 
the same as for the removal of a finger at the metacarpo- 



AMPUTATIONS OF THE FINGERS 



565 



phalangeal joint, the incision being prolonged backward as 
far as necessary over the dorsal surface of the bone (Fig. 391) . 
After the metacarpal bone has been bared for a sufficient 
distance it is cut through with bone pliers or disarticulated, 
and the distal end is raised from its bed and carefully sepa- 
rated from the soft parts, care being taken to avoid injury 
of the structures of the palm of the hand: 



Fig. 391. 




A, disarticulation of distal phalanx (palmar flap) ; B, amputation in continuity by 
a circular flap; C, metacarpophalangeal disarticulation; D, amputation of metacarpal 
bone in continuity; E, disarticulation of little finger; F , disarticulation of fifth meta- 
carpal bone; G, amputation at the wrist, circular; H, amputation at the wrist, lateral. 

In amputating the fifth metacarpal bone the incision should 
be made along the inner border of the hand and carried down 
to the bone between the skin and the abductor minimi digiti 
muscle (Fig. 393). The lower end of the incision passes over 
the knuckle to the web of the finger and backward under 
the palmar surface to join the first incision. 



566 



OPERATIONS 



Amputation of the entire thumb with its metacarpal bone 
is effected by making an oval flap from the palmar surface ; in 



Fig. 392. 




Removal of the head of a metacarpal bone. 



the case of the left thumb the joint may be opened by an 
oblique incision on the dorsal surface of the hand, beginning 
a little in front of the joint and being carried down to the web 



Fig. 393. 




Incision for removal of the fifth metacarpal bone. 

between the thumb and forefinger; the palmar flap is then 
made by thrusting the knife upward to its point of entrance 



AMPUTATIONS OF TOES 567 

and cutting downward and outward. In amputating the 
right thumb with its metacarpal bone it is better to make 
the palmar flap first by transfixion, the dorsal flap being made 
subsequently. 

In amputations involving portions of the hand the super- 
ficial and deep arches are divided and numerous vessels 
require ligature. 

Amputation of the hand at the carpo-metacarpal joint is 
occasionally performed, or between the rows of carpal bones; 
but is not, as a rule, to be recommended, as the carpal bones 
are apt subsequently to become diseased and require removal; 
it is, therefore, better to amputate at the radio-carpal joint. 

Dressing of Amputations of Fingers and Hand. — The bleed- 
ing vessel should be secured by ligatures. Before approx- 
imating the flaps in amputations of the fingers and meta- 
carpal bones it is wise to introduce drainage — a few strands of 
catgut or silkworm gut or narrow strips of rubber dam. The 
great vascularity of these parts causes oozing of blood from 
many minute points which cannot be tied, and if the stump 
is tightly closed, blood clot is apt to accumulate under the 
flaps, causing pain and impairing their vitality. A sterilized 
gauze dressing is next applied and secured by a bandage. 
The application of a palmar splint to the hand and forearm 
keeps the part safe from injury and the rest of the parts 
favor prompt repair. 

AMPUTATIONS OF TOES AND METATARSAL BONES. 

Amputations of the Toes. — The phalanges of the toes may 
be removed in the same manner as those of the fingers. It 
is better to amputate at the metatarso-phalangeal articu- 
lations than to attempt to remove them at the joints in 
front of this articulation, except in the case of the great 
toe, as the preservation of a portion of a toe is rather a dis- 
comfort than an advantage, except in the instance mentioned. 
The heads of the metatarsal bones should be retained when- 
ever possible, as they afford great support to the foot in 
walking. All incisions should be made so that the resulting 
cicatrix does not occupy the plantar surface, and it is well 



568 



OPERATIONS 



to remember that the web of the toes is considerably below 
the position of the metatarso-phalangeal joint. 

The toes are usually removed by an incision on the dorsal 
surface a little above the joint, which is carried down to the 
bone for about 1 inch and then diverges into the web, and is 
carried under the toe and back on the other side to the point 
of divergence (Figs. 394 and 395). 



Fig. 394. 



Fig. 395. 





Amputation of the toes by the racket- 
shaped incision and flap method. 



Incisions for amputation of toes and 
metatarsal bones. 



Amputation of Two Adjoining Toes.— The dorsal incision 
should be made in the inter-metatarsal space just above the 
level of the joint (Fig. 395) and carried down to the beginning 
of the web; then over the toes to the beginning of the 
adjoining web ; then under the plantar surface of both toes 



AMPUTATIONS OF TOES 



569 



in the line of the digito-plantar fold, through the web and 
back to the point of divergence. 

Amputation of the Great Toe.— This may be accomplished 
by means of the racket-shaped incision employed in amputa- 
tion of the other toes (Fig. 394), or by means of a lateral flap. 
In the latter case the knife is made to enter the joint by 
cutting through the commissure and the operation is com- 
pleted by carrying the knife through the joint and along 
the outer side of the bone, forming a flap of the required size. 
In this amputation a short dorsal flap and a long plantar 
flap may be employed or a large internal flap may be used. 

Fig. 396. 




Amputation of the great toe and first metatarsal bone. 



Amputation of the Great Toe with its Metatarsal Bone. — The 
incision begins upon the dorsal surface of the metatarsal 
bone, a little below the point at which the bone is to be 
divided, and is carried down below the metatarso-phalangeal 
joint, then diverges and passes under the toe and comes back 
again to the point of divergence (Fig. 395). The bone is 
exposed and cut through with cutting forceps, and is then 
lifted up and dissected loose from the tissues (Fig. 396). 

Amputation of All the Toes. — To amputate all the toes make 
a dorsal incision from the head of the fifth to the head of the 



570 OPERATIONS 

first metatarsal bone; the incision should be a curved one 
passing just in front of the joints (Fig. 397). Dissect up 
the flap and open the joints, dividing the lateral ligaments and 
pass the knife behind the phalanges and cut a flap from the 
plantar surface. 

Fig. 397. 

fV 




Incision for amputation of all the toes. 

Amputations of the Metatarsal Bones. — It is better in these 
amputations to leave the tarsal head of the metatarsal bone 
in place and divide the bone, or, in other words, to do an 
amputation in continuity to prevent opening up the tarsal 
articulations. 

Amputation of the Little Toe and the Fifth Metatarsal Bone. 
— The incision for the removal of the little toe and the fifth 
metatarsal bone is made over the bone a little below the 
metatarso-tarsal articulation, and is carried down and curved 
around the toe (Fig. 395, D), and after the bone is exposed 
by dissecting back the flaps it is divided, or the joint is opened 
and it is dissected out. 

Amputation through All the Metatarsal Bones. — In perform- 
ing this amputation an incision is made across the dorsum 
of the foot, and a short dorsal flap is dissected up; the meta- 
tarsal bones are next divided with a saw and a long plantar 
flap is cut from within outward by entering the knife behind 
the ends of the bones. After amputation of one or more of 
the toes or portions of the metatarsal bones, after controlling 
the bleeding by ligatures, drainage, as in care of the fingers, 
should be introduced and the flaps approximated by sutures. 



CALLOSITY 571 

A gauze dressing is next applied and held in place by a 
bandage. 

Warts or Verruca. — A wart consists in a localized hyper- 
plasia of the epidermis. It may be smooth, firm and rounded 
in outline or present an irregular, granulated or cauliflower 
surface. The favorite sites for warts are the skin of the back 
of fingers and hands, face, scalp and neck. They usually 
appear to grow spontaneously; in some cases a suspicion of 
contagion exists. They are most common in children and 
young adults. They show little tendency to enlarge and 
occasionally disappear spontaneously. 

Treatment. — This consists in touching the surface with 
nitric, acetic or chromic acid or the application of solid C0 2 ; 
in a few days the wart shrivels and falls off. They may be 
snipped off with scissors and the base touched with the solid 
stick of nitrate of silver. Electrolysis may also be used for 
their removal. 

Venereal warts have no necessary connection with venereal 
disease, although they frequently occur in connection with 
this disease where the parts become irritated by filthy dis- 
charges. They are frequently observed upon the moist skin 
around the anus, vulva or inner surface of the prepuce. 
They may be successfully treated, if the surfaces from which 
they grow are kept dry, by washing them with peroxide of 
hydrogen, drying with cotton and dusting them with a 
powdered talcum and oxide of zinc, equal parts, or one of 
calomel, 5j; bismuth, 3ij; oxide of zinc, 3j- Where very 
extensive, excision and cauterization of their bases may be 
required. 

Papilloma. — This is an epithelial tumor growing from the 
skin or mucous membrane. It consists of a fibrous stroma 
which contains bloodvessels and lymphatics and is covered 
by epithelium. It is frequently observed upon the mucous 
surface of the lips, cheeks and tongue. Those of the skin 
are usually firm, while those upon the mucous surfaces are 
soft. The treatment consists in excision of the growth and 
cauterization of its base with cautery or acid. Desiccation 
' with the high frequency current is now much used for this 
purpose. 



572 OPERATIONS 

Callosity. — This is an hypertrophied condition of the epi- 
dermis in the palms of hands and soles of the feet, and is 
occasionally seen in the skin of other parts of the body, and 
results from long-continued pressure or friction. 

Clavus or Corns. — This is a painful circumscribed thicken- 
ing of the epidermis, which may develop in the center of a 
callosity or upon the exposed surface of the toes. There is a 
pyramidal-shaped outgrowth of epithelial cells, which sepa- 
rates the papilla of the skin and causes pain by pressure on 
the sensitive nerve endings. A soft corn originates from the 
moist surfaces of the lateral aspects of the skin of the toes. 
When of long duration a bursa may develop under a hard 
corn, giving rise to a bunion which is most commonly observed 
over the metatarso-phalangeal articulation of the great toe. 

Treatment. — This consists in removing the cause of pressure 
by the wearing of proper shoes, the use of an ointment of 
salicylic acid (5 to 10 per cent) or wearing over the corn a 
salicylated plaster (20 per cent) and protecting the part from 
pressure by a shield. After using this ointment or plaster 
the softened corn may be lifted'off. Bunion is best treated 
by excision of the enlarged bursa. 

Sebaceous Cysts or Wen. — This occurs from the excretory 
duct of a sebaceous gland becoming occluded by foreign 
matter or inflammation. They occur with the greatest fre- 
quency upon the scalp, face, neck and back, and are often 
multiple. They are rarely seen below the level of the umbili- 
cus. Sebaceous cysts are occasionally observed on the skin 
of the scrotum. The skin is adherent to the cyst at the orifice 
of the duct and it contains a malodorous wax-like material. 
They frequently become infected and suppurate, and dis- 
charge pus mixed with sebaceous material. 

Treatment. — The opening of the duct can be recognized by 
a dark spot. After sterilizing the surrounding skin or scalp, 
this is circumscribed by an incision, and the cyst can be 
dissected out, care being taken not to rupture the sac, but 
remove the whole of the sac, for if even only a small portion 
is left a new cyst develops. One or two sutures of catgut may 
be introduced to approximate the skin or scalp and a gauze 
pad and bandage are applied. A dressing of gauze strips 
held in place by benzoin and collodion may also be used. 



PARACENTESIS ABDOMINALIS 573 

Inflamed cysts are difficult to remove. In such cases it is 
better to open the cyst, curette out its contents, cauterize 
the inner surface with carbolic acid and allow the wound to 
heal; and if the cyst wall is not destroyed later remove the 
sac when it is not inflamed and after it again has begun to 
become distended. 

The late Prof. Ashhurst, in removal of sebaceous cyst of 
the scalp, passed a narrow bistoury through the base of the 
cyst and cut directly outward; then with two pairs of forceps, 
one grasping the skin, the other the edge of the sac, by trac- 
tion enucleated the sac and its contents. I have frequently 
employed this method, dealing with cysts of the scalp, and in 
spite of the chances of infection, it rarely seems to occur, 
and repair occurs promptly. This method is not satisfactory 
for the removal of inflamed sebaceous cysts. 

Paracentesis Thoracis. — This may be done with an ordi- 
nary trocar and cannula, but it is better to employ an aspi- 
rator. For purposes of diagnosis a hypodermic syringe with 
a long needle may be used. The instrument and the skin 
over the area in which the tapping is to be made are sterilized 
with tincture of iodine, and the patient is placed in a semi- 
recumbent posture. The site of the exploration is located 
by the physical signs elicited by percussion and auscultation 
and usually is an intercostal space between the sixth and 
eighth rib in the midaxillary line. A puncture is made 
through the skin over the upper edge of the rib. This 
position is selected to prevent injury of the intercostal vessels 
and the skin is drawn upward and the aspirating trocar is 
passed through the puncture into the chest near the upper 
edge of the rib, the trocar is removed and the stopcock is 
turned, which allows the fluid to enter the vacuum bottle. 
After the fluid has been removed the aspirating cannula is 
removed and the small wound is sealed with pledget of gauze 
and collodion. 

Paracentesis Abdominalis. — This operation may be re- 
quired for the withdrawal of extravasated serum. It may 
be done with trocar and cannula, or with an aspirator. The 
latter is better as it prevents the admission of air. The 
patient should be in the sitting posture and the bladder 
should be empty. 



574 OPERATIONS 

The point usually selected is in the median line, from 2 to 
3 inches below the umbilicus. This is the thinnest part of 
the abdominal wall and is free from large vessels. The 
surgeon should satisfy himself that bladder is empty before 
introducing the trocar. 

The skin and instrument being sterilized, a puncture is 
made through the skin with a sharp-pointed knife, and the 
aspirating trocar is made to enter this puncture and gently 
pushed through the abdominal wall. The surgeon should 
watch to note the depth to which the trocar is passed. The 
trocar is next removed and the stop-cock turned, which 
allows the fluid to escape in the vacuum bottle. If the fluid 
fails to escape, either the instrument has not been introduced 
sufficiently far enough or the omentum may have occluded 
the cannula; by further introduction or changing the position 
of the cannula the difficulty may be removed and the fluid 
escapes. 

Sometimes, on account of the condition of the patient, it is 
not advisable to remove all of the fluid at one sitting. Some 
surgeons apply a many-tailed bandage to the abdomen with 
the tails secured on the back. This is gradually tightened and 
secured with pins as the abdomen becomes emptied of fluid. 

When the fluid has been removed the cannula is removed 
and the puncture sealed with a pledget of gauze and collodion. 
If serum continues to escape from the puncture, as often 
occurs, a sterilized gauze pad should be secured over the 
wound. This leakage usually stops within a few hours. 

A firm, many-tailed bandage should next be applied and 
is a comfortable dressing for the patient. 

Paracentesis Pericardii. — This operation may be required 
to remove serum or purulent fluid from the pericardium. 
The aspirating trocar is introduced through the skin in the 
fifth left intercostal space 2 inches to the left border of the 
sternum, external to the internal mammary artery. A mod- 
erate-sized aspirating needle should be used, as it is advisable 
to have the fluid escape slowly. The needle is removed and 
the wound sealed with gauze and collodion. The pericardium 
may also be reached by a puncture in the fourth or fifth inter- 
space, near the border of the sternum, which avoids the pleura 
and internal mammary artery. 



LUMBAR PUNCTURE 



575 



Fig. 398. 



Paracentesis Vesicae. — In cases of impassible stricture, as 
a temporary procedure, a distended bladder is sometimes 
emptied by aspiration. There is always risk of infection of 
the tissues in the line of puncture by the urine; so this pro- 
cedure is to be avoided if possible. A trocar and cannula or 
an aspirating trocar is introduced through the tissues imthe 
middle line just above the pubes; 
the urine is withdrawn, and, after 
removing the cannula, the punc- 
ture is sealed with a pledget of 
gauze and collodion. 

Lumbar Puncture. — This pro- 
cedure is frequently employed for 
diagnostic and therapeutic purposes. 

The skin of the lumbar region is 
sterilized with tincture of iodine 
and may be anesthetized by in- 
jecting a few drops of a 2 or 4 per 
cent novocaine solution. The pa- 
tient is next made to bend forward 
and the tip of the spinous process 
of the fourth lumbar vertebrae is 
located by the left index finger. 
The needle attached to an empty 
syringe is made to penetrate the 
skin J inch to the right and just 
below the tip of this process and 
is pushed forward, inward (toward 
the median line) and slightly up- 
ward into the intraspinous space between the fourth and fifth 
lumbar vertebra? (Fig. 398). The entrance of the needle 
into the subarachnoid space is shown by the sense of lessened 
resistance. The distance penetrated is from 2\ to 3 inches. 
If the needle is in the subarachnoid space upon drawing out 
the piston of the syringe, clear cerebrospinal fluid will 
appear in the syringe. 

It is permissible and may be easier to introduce the needle 
in the median line ; also a higher level than the fourth lumbar 
interspace may be used. 

After removing a sufficient quantity of fluid the needle 




Lumbar puncture showing 
position of needle. 



576 



OPERATIONS 



is withdrawn and the small wound is sealed with gauze and 
collodion. 

Spinal puncture is the preliminary step in the injection of 
drugs to produce spinal anesthesia, the introduction of 
tetanus antitoxin and the removal of cerebrospinal fluid to 
relieve pressure in cases of fracture of the base of the skull, 
and in cases of cerebrospinal meningitis, anterior poliomyelitis 
and hydrocephalus. For diagnostic purposes in certain cases 
examination of the spinal fluid is of great value. 



Fig. 399. 




Circumcision. 

Circumcision. — Circumcision is performed by drawing the 
prepuce forward and then clamping it with the handles of a 
pair of scissors or a pair of clamp forceps placed obliquely 
just in front of the glans (Fig. 399). The prepuce is next 
divided with a straight bistoury, and the forceps removed, 
when the skin and mucous membrane retract. The mucous 
membrane, if adherent, is dissected loose from the glans; if 
redundant it is trimmed with scissors to make it correspond 
to the line of skin incision; the cut edge of the mucous mem- 
brane is next fastened to the cut edge of the skin by a few 
sutures of silk or fine catgut. Catgut is the best suture 
material to use in children, as the sutures are absorbable and. 



TREATMENT OF HYDROCELE 577 

do not require removal which is often a troublesome pro- 
cedure in this class of patients. 

Varicocele. — In operating for varicocele, after sterilizing the 
skin of the scrotum or of the groin, the veins of the spermatic 
cord may be exposed by an incision 1J or 2 inches in length 
at the upper part of the scrotum, over the cord, or the cord 
may be exposed by an incision in the groin as it emerges from 
the inguinal canal, as recommended by Binnie. The veins 
being exposed, the larger portion of them are isolated, and 
two ligatures are passed around the mass of veins about 1 
or 1J inches apart and firmly tied, care being taken that the 
vas deferens is not included with the veins. The portion of 
the veins between the ligatures is excised and the divided 
ends of the veins brought in contact by tying together the 
ends of the ligatures upon the proximal and distal ends of the 
veins; the wound is then closed with sutures. 

Treatment of Hydrocele. — The Palliative Treatment. — It is 
well to examine the tumor for translucency with transmitted 
light to discover if there is any abnormal position of the 
testicle. Old hydroceles with thickened sacs and those in 
which hemorrhage has occurred are opaque. The skin of the 
scrotum should be sterilized and the tumor rendered tense by 
grasping it with the hand; a sterile trocar is then introduced 
through the anterior wall of the scrotum into the cyst, care 
being taken to avoid wounding any large superficial vein, 
being directed upward and backward to avoid wounding the 
testicle. After the fluid has escaped the cannula is removed 
and the puncture sealed with a sterile piece of gauze or cotton 
and collodion. 

Injection Treatment. — This consists in emptying the cyst by 
means of a trocar and injecting from 1 to 2 drams of tincture 
of iodine. Another method consists in first introducing the 
needle of a hypodermic syringe, charged with 10 to 12 drops 
of pure carbolic acid, into the upper part of the sac — this is 
held by an assistant. The sac is next emptied by introduc- 
ing a trocar at a lower portion of the cyst. After removing 
the fluid the carbolic acid is injected into the cyst and evenly 
distributed by rubbing the walls together. The instruments 
are removed and the punctures sealed with gauze and collo- 
37 



578 



OPERATIONS 



Fig. 400. 



dion. Pain and swelling follow each of these operations, but 
usually subside in forty-eight hours. The injection treat- 
ment was formerly frequently employed, but in recent years 
has been superseded by the operative methods of eversion 
or excision of the sac. 

Eversion of Sac. — An incision is made exposing the sac for 
several inches, it is then incised and emptied and the testicle 

is brought out through the wound. 
The gubernaculum testis is next 
ligated and divided, then fold the 
two sides of the divided sac behind 
the testicle and fix them by a few 
sutures, one of which should inter- 
sect the superficial tissue of the 
cord (Fig. 400). The testicle is 
then replaced in the scrotum and 
the wound closed with sutures 
without drainage. 

Excision of the Sac. — This con- 
sists in making an incision 2 or 3 
inches in length over the anterior 
surface of the scrotal tumor, and 
dividing the tissues until the sac is 
exposed. This is next incised and 
the parietal layer is dissected out 
as far as possible and the testicu- 
lar portion of the tunica vaginalis 
lightly scarified to destroy its secre- 
tory surface; a strip of rubber 
tissue or a gauze pack is intro- 
duced and allowed to remain for forty-eight hours and is 
then removed. The wound usually heals in from ten days 
to two weeks." Recurrence after the injection or eversion 
treatment is not infrequent, but seldom occurs after excision 
of the sac. 

Ingrown Toenail. — In this condition the edge of the nail 
usually of the great toe, by pressure upon the flesh beneath it, 
causes ulceration or suppuration. The condition is painful 
and causes marked disability. It may be treated by care- 




Operation for hydrocele by 
eversion method. 



INGROWN TOENAIL 



579 



fully introducing a little wisp of cotton under the edge of the 
nail raising it away from the ulcer, and applying to the cotton 
a few drops of collodion and tincture of benzoin, which satu- 
rates the cotton and becomes dry forming a scab on which the 
edge of the nail rests. This dressing should be repeated at 
intervals of a few days and will often result in complete relief 
of the condition. 

In aggravated cases operative treatment is often required. 
The essential point is to remove both the edge of the nail 
and that portion of the matrix from which it grows. The 

Fig. 401. 




Operation for ingrown toenail. 1, line of incision; 2, skin flaps reflected; 3, section of 

nail and matrix removed. 



following operation will be found satisfactory: Sterilize the 
toe as completely as possible and tie a rubber band around 
its base; inject a few drops of a eucaine or novocaine solution 
along the edge of the nail and beneath it as far back as the 
second phalanx. Make an incision through the nail and 
overlying skin and matrix about J inch from the edge of 
the nail (Fig. 401, 1). The overlying skin is next dissected 
free from the edge of the nail and its matrix (Fig. 401, 2). 

The portion of the nail marked out by the first incision is 
then dissected out with its matrix, care being taken that 
all of the matrix corresponding to the nail is removed (Fig. 



580 OPERATIONS 

401, 3). The wound is irrigated with a 1:2000 bichloride 
solution and closed by wrapping a gauze dressing around the 
toe and securing it by a bandage firmly applied. The rubber 
bandage is next removed. The wet dressing should be 
renewed daily for a few days, and after this time a dry dress- 
ing may be employed. 

Paronychia. — This is an infection of the base of the finger- 
nails, commonly known as run-around. The infection usu- 
ally results in a small subepithelial abscess involving the 
tissues on one side of the nail, which, if not promptly opened, 
spreads along the base of the nail to the other side. If not 
relieved by incision the nail becomes separated at its base 
and is cast off. 

Fig. 402. 





Lines of incision in paronychia. (Kanavel.) 

Treatment. — This consists in making a longitudinal inci- 
sion on one or both sides of the outer edge of the nail as far 
back as the sulcus. In cases of some standing it is well to 
push back the eponychium, and with the point of a scissors 
inserted under the detached edge of the nail cut off as much 
of the root of the nail as has become separated from the 
matrix. 

Felon or Whitlow. — This may consist: (1) The subcuticular 
felon, which consists of a collection of pus under the epi- 
dermis, in which, after incision and evacuation of the pus 
and the removal of the dead skin, pain is relieved and a 
prompt recovery takes place. 

2. The subcutaneous form, which consists in a cellulitis of 
the pulp of the finger or thumb over the last phalanx, result- 
ing from infection through a puncture or abrasion. The 
inflammatory condition results in severe throbbing pain and 
swelling of the parts. Unless the condition is relieved by 



FELON OR WHITLOW 581 

incision the bone may become involved or the process may 
extend to the tendon sheath. 

The treatment consists in early and free incision and the 
subsequent use of hot antiseptic dressings. The incision 
should be made as soon as the edema restricted to the first 
phalanx has developed to the point of producing hardness of 
the tissues. It should not be made in the center of the finger, 
but at the side to avoid a scar over the site of the tactile por- 
tion of the finger. 

3. Suppurative Thecitis. — This may follow the variety just 
described or may arise from infection of the tendon sheath 
from wounds. Pain, swelling and disability of the fingers 

Fig. 403. 



Lines of incision to open various tendon sheaths. (Kanavel.) 

are prominent symptoms. If the condition is not arrested 
by treatment suppuration may extend along the tendon 
sheaths to the palm of the hand and give rise to palmar 
abscess. Sloughing of the tendon is apt to occur and may 
result in a useless finger. This condition is more likely to 
occur when either the little finger or thumb is involved, 
because their tendon sheaths communicate with the common 
palmar sac. 

Treatment. — The patient should be anesthetized and a care- 
ful dissection should be made through the inflamed tissues 
parallel to the sheath of the tendon to evacuate the purulent 
matter. The lines of incision employed to open the various 
tendon sheaths is shown in Fig. 403. If pus is found external 



582 OPERATIONS 

to the sheath this should not be opened, but if the sheath is 
found distended it should be opened at one or more points 
to secure free drainage. The tendon sheaths or thecal sacs 
in connection, if infected, should, after being opened, be 
irrigated with an antiseptic solution or with saline solution. 
Hot antiseptic dressings should be applied, and the hand 
should be put at rest upon a splint. Bier's hyperemic treat- 
ment may be used with advantage in these cases. 

Palmar Abscess. — This consists in a collection of pus 
beneath the palmar fascia and may develop from an infection 
arising in the tendon sheaths of the fingers or from wounds, 
contusions or abrasions of the palm of the hand. As the pus 
accumulates under the palmar fascia, marked swelling and 
edema of the back of the hand may occur. Severe pain, 
throbbing in character, and swelling of the hand are promi- 
nent symptoms. If the condition is not relieved promptly 
by operation sloughing of the tendons may occur. 

A thecal abscess of the index, ring or middle finger is usually 
arrested in the palm, and if ruptured, pus escapes giving rise 
to a palmar abscess. In suppurative thecitis of the little 
finger or thumb the pus may follow the tendon sheaths into 
the forearm. 

Treatment. — The patient should be anesthetized and a care- 
ful incision should be made into the tissues of the palm, the 
line of incision should correspond to the middle of the meta- 
carpal bones and should be distal to a line crossing the palm 
at the level of the web of the thumb to avoid the superficial 
palmar arch. When the palmar fascia has been opened the 
pus usually escapes freely. If there is much swelling of the 
back of the hand incisions may be required at this point. 
Strips of rubber dam, or rubber drainage tubes, should be 
introduced into the incisions, a moist antiseptic gauze dress- 
ing applied and the hand should be placed upon a palmar 
splint. 

Tracheotomy. — This operation consists in dividing the 
tissues over the trachea in the median line of the neck, and 
after the trachea has been exposed it is opened by dividing 
two or three of the tracheal rings. 

The instruments required are two small scalpels, one short 



TRACHEOTOMY 



583 



grooved director, a tenaculum, two aneurysm needles (which 
may be used as retractors), hemostatic forceps, two pairs of 
dissecting forceps, a pair of scissors, a pair of tracheal forceps, 
a tracheal dilator, tracheotomy tubes, tapes, ligatures, gauze 
sponges, a flexible catheter and feathers. The director should 
be short; the ordinary grooved director is too long to use 
with satisfaction in operating upon the short necks of chil- 
dren (Fig. 404). 

Hemostatic forceps are also useful in controlling hemor- 
rhage during the operation in case of the division of vessels 
which bleed freely, when the operator from the urgency of 
the case does not think it justifiable to ligate them at the time 
of their division. They may also be employed under similar 
circumstances to clamp the isthmus of the thyroid gland on 
either side of the trachea when it becomes necessary to divide 
it to expose the trachea. 

Fig. 404. 




Author's tracheotomy director. 



Tracheal dilators of various kinds are employed, but the 
most satisfactory tracheal dilator which I have employed is 
that of Golding-Bird (Fig. 405), which is a self-retaining 
instrument; the blades are slipped through the tracheal 
incision and are then expanded by turning the screw to which 
they are attached. Trousseau's tracheal dilator, the blades 
of which are introduced through the incision in the trachea 
and are expanded by bringing together the handles, is also 
a satisfactory instrument (Fig. 406) . Tracheal dilators may 
be improvised from bent hair-pins or pieces of wire, which 
will often serve a useful purpose where ordinary dilators 
cannot be obtained. 

It is also well to have at hand a number of pliable feathers, 
to be used in clearing the trachea or larynx of mucus or 
membrane after it has been opened; by their use this object 



584 



OPERATIONS 



may be accomplished with little risk of injury to the mucous 
membrane. 

Tracheal forceps, which are constructed with a double 
spring and curved blades, are also useful in removing mem- 
brane or foreign bodies from the larynx above the wound or 
from the trachea below the tracheal incision (Fig. 407). 



Fig. 405. 



Fig. 406. 





Golding-Bird's tracheal dilator. 



Trousseau's tracheal dilator. 



Tracheotomy tubes of various shapes are made of silver, 
aluminum, hard and soft rubber, but the tube which I con- 
sider the most satisfactory for general use is a silver quarter- 
circle tube with a movable collar (Fig. 408), and provided 
with a fenestrated guide (Fig. 409). A satisfactory trache- 
otomy tube is one which inflicts the least possible injury upon 



Fig. 407. 




Tracheal forceps. 

the mucous membrane of the trachea, and to insure this 
object the part of the tube within the trachea should lie 
exactly in its axis, and its free extremity should be capable 
of as little movement as possible. The tracheotomy tube is 
held in position, after being introduced, by means of tapes 
attached to the shield of the tube and tied around the neck. 



POSITION OF PATIENT FOR TRACHEOTOMY 585 

Position of Patient for Tracheotomy. — The best position in 
which to place the patient for this operation is one which 
brings the neck into the greatest prominence, and this may 



Fig. 408. 



Fig. 409. 





Silver tracheotomy tube. Silver tracheotomy tube with fenestrated guide. 

best be obtained by laying the patient upon his back upon a 
firm table and placing under the shoulders a round cushion; 



Fig. 410. 




Position of patient for tracheotomy. 



or an empty wine bottle or a roller-pin wrapped in towels, 
will answer the same purpose (Fig. 410) ; or the head may be 
held over the edge of the table. If an anesthetic is not used 



586 OPERATIONS 

the arms should be held by an assistant. An anesthetic is 
contraindicated in dyspnea. 

Operation of Tracheotomy. — The trachea may be opened 
above the isthmus of the thyroid gland or below it, and 
these operations constitute respectively the high and the low 
operation. 

The high operation is generally selected because at this point 
the trachea is more superficial and is more easily exposed, 
whereas in the low operation the trachea is more difficult to 
expose by reason of its relatively greater depth, the large size 
and number of veins, and its proximity to the large arterial 
trunks. 

High Operation. — The patient being placed in position, the 
operator stands at the head of the patient; this position I 
prefer, as it is easier from this point to keep the incisions 
exactly in the median line of the neck. The operator next 
makes himself familiar with the landmarks of the neck; locat- 
ing the position of the cricoid cartilage, he makes an incision 
through the skin in the median line of the neck from 1| to 
2 inches in length, the position of the cricoid cartilage being 
the middle point. There is no disadvantage in making a 
longer incision if a freer exposure of the parts is required. 
Having divided the skin, the operator will often see a large 
vein lying in the superficial fascia— the superficial anterior 
jugular; this should be displaced and the fascia divided upon 
a director. 

The surgeon should keep his incisions strictly in the median 
line of the neck, for this is the line of safety; and he should be 
careful, as the wound increases in depth, not to make the 
incisions too short, so that the wound becomes funnel-shaped. 
When the deep fascia is exposed it should be picked up and 
divided upon a director; any large veins in the line of the 
wound should be carefully displaced, or, if this is impossible, 
they should be ligated on each side and then divided between 
the ligatures. 

The operator next looks for the intermuscular space 
between the sternohyoid and the sternothyroid muscles, which 
may generally be found without difficulty; the muscles are 
now separated in this line, with the handle of the knife or 



OPERATION FOR TRACHEOTOMY 587 

with a director, and the isthmus of the thyroid gland exposed. 
The muscles should now be held aside by retractors placed on 
either side. He should carefully explore the wound with the 
finger to locate exactly the position of the trachea, and to 
ascertain, if possible, the presence of anomalous arteries. 

The isthmus of the thyroid gland having been exposed, 
which generally occupies a position over the first three 
tracheal rings, the gland will be found surrounded by a plexus 
of veins, which should be displaced with the director; or, if 
this is impossible they should be ligated on each side and 
divided between the ligatures. The thyroid isthmus is next 
displaced upward Or downward, according as the surgeon 
desires to open the trachea below or above this body. This 
is often done without difficulty, especially its upward dis- 
placement; but when there is difficulty in displacing it down- 
ward, a procedure recommended by Bose may be employed, 
which consists in making a transverse incision across l the 
cricoid cartilage to divide the layer of fascia by which the 
isthmus is bound down; the director is then passed into this 
incision and the isthmus is depressed without difficulty. 

Having displaced the isthmus of the thyroid gland down- 
ward, the trachea, yellowish-white in appearance, covered by 
the tracheal fascia, will be exposed; this fascia should next 
be thoroughly broken up with a director or the handle of the 
knife, so as to bare the trachea, and in doing this the operator 
may feel it crepitate under the finger from the suction of air 
drawn in with inspiration. The trachea is next fixed with 
a tenaculum, introduced into it a little to one side of the 
median line; an incision is made into it with a narrow knife 
from below upward, from i to f inch in length (Fig. 411), 
care being taken to see that this incision is in the median line, 
for if the trachea be opened by a lateral incision the wound 
does not heal so promptly and the tracheotomy tube does not 
fit well, and its lower extremity may cause injury to the 
mucous membrane of the trachea. If the wound be a deep 
one, after fixing the trachea with the tenaculum the operator 
may lift it slightly from its bed, thereby bringing it more 
prominently into view and making it more superficial in the 
wound, thus facilitating its opening. As soon as the incision 



588 



OPERATIONS 



is made into the trachea, air mixed with blood and mucus 
escape from the incision. A tracheal dilator should next be 
introduced and the trachea cleared of membrane, if it is 
present in the region of the wound, with a feather or with 
forceps. The tracheotomy tube is next introduced, and is 
secured in position by tapes tied around the neck. If respi- 
ration has ceased artificial respiration should be resorted to. 
If possible the first tracheal ring should not be divided in 
order to avoid subsequent stricture. 

Fig. 411. 




Opening of the trachea. 

Laryngotomy. — In this operation an opening is made into 
the air passages through the cricothyroid membrane. It is a 
simple operation, and one which is practically free from risk, 
and can, therefore, be performed much more rapidly and 
safely in urgent cases than tracheotomy. 

The patient being placed in the recumbent posture, with 
the shoulders slightly elevated and the head thrown back to 
make the neck as prominent as possible, the surgeon feels for 
the prominence of the thyroid cartilage, and steadying the 
larynx between the finger and thumb of the left hand, he 
makes an incision in the median line over the center of the 
thyroid cartilage and extending downward for 1 or 1 J inches. 
The skin and superficial fascia being divided, the fascia 
between the sternohyoid muscles and the areolar tissue is 



INTUBATION OF THE LARYNX 589 

exposed and divided, and the cricothyroid membrane is 
exposed. The knife is then passed transversely through the 
membrane into the larynx, care being taken that both that 
membrane and the mucous membrane which covers its inner 
surface are divided at the same time. As soon as the knife 
enters the cavity of the larynx blood and mucus will be 
forcibly expelled. 

The wound should be carefully enlarged and a tube intro- 
duced, which differs from the ordinary tracheotomy tube in 
being slightly flattened; this is secured in position by tapes 
tied around the neck as in the case of the ordinary tracheal 
tube. The only bleeding which is likely to occur is from the 
cricothyroid artery or veins, and if these cannot be avoided, and 
are divided in the operation they should be temporarily 
secured by hemostatic forceps or ligated; if the case is not 
extremely urgent all bleeding should be arrested before the 
cricothyroid membrane is incised. 

Laryngo-tracheotomy. — This operation consists in making 
an incision into the air passages by dividing one or two of the 
upper rings of the trachea, the cricotracheal membrane, the 
cricoid cartilage and the cricothyroid membrane. This oper- 
ation is employed in cases where, from the age of the patient, 
the cricothyroid space is too small to admit of a sufficient 
opening, or in those in which, for any reason, the surgeon 
does not deem it advisable to attempt to open the trachea 
lower down. The incision in the skin and superficial fascia 
of the neck is made in the same manner as in the operation 
of laryngotomy, but is carried a little further downward. It 
may be necessary to displace the isthmus of the thyroid gland 
downward to expose the upper portion of the trachea, and 
when the trachea is exposed the incision should be made 
through this and the cricoid cartilage from below upward. 
A tracheotomy tube is introduced through the wound and 
secured by tapes tied around the neck. 

Intubation of the Larynx. — This procedure at the present 
time, is widely employed as a substitute for tracheotomy in 
the treatment of dyspnea due to inflammatory affections of 
the larynx or trachea, or stenosis of the larynx; it consists in 
the introduction of a metallic or hard-rubber tube into the 
larynx, which is allowed to remain in place for a few days. 



590 



OPERATIONS 



This operation has been introduced to the profession by the 
late Dr. O'Dwyer, of New York, who devised a set of ingeni- 
ous instruments for the purpose of laryngeal intubation. 



Fig. 412. 




Mouth gag. 



The instruments required are a mouth gag (Fig. 412), with 
which the jaws are separated and held open; an instrument 
for the introduction of the tube, which is fastened to the 
obturator, which fills the cavity of the tube (Fig. 413) and an 



Fig. 413. 




Intubation tube and introducer. 



instrument for extracting the tube after it has been placed 
in the larynx (Fig. 414). The tubes are of metal or hard rub- 
ber, and have a collar which rests upon the false cords, and 



OPERATION OF INTUBATION OF THE LARYNX 591 

bulge slightly toward their middle and again taper toward 
their lower extremity; at the collar of the tube there is a 
perforation through which a strand of silk is passed which is 
made into a loop; this is used to enable the operator to 
remove the tube if on its introduction it is found to have 
passed into the esophagus instead of the larynx, and is also 

Fig. 414. 




Intubation-tube extractor. 



useful in removing the tube if it becomes occluded with mem- 
brane while in the larynx. The intubation set now in com- 
mon use is provided with a scale of seven tubes, ranging in 
size from such as are suited for a child of one year or less up 
to the age of twelve or fourteen years (Fig. 415). Special 
tubes are required for intubation in adults. 



Fig. 415. 




Scale of intubation tubes. 

Operation of Intubation of the Larynx.— In performing the 
operation of intubation, the child is placed upon the lap of 
the nurse or assistant, wrapped in a blanket, and the arms 
secured by the nurse holding the elbows so as not to interfere 
with the respiratory movements. The patient's head is next 
held by an assistant. The position of the head, neck and 
body should be as if the child were hung from the top of the 
head, and this position should be maintained during the 
insertion of the tube. An intubation tube can be introduced 
without difficulty with the patient in a recumbent posture. 



592 



OPERATIONS 



This position should be utilized when it is not desirable to 
place him in the sitting posture. The mouth gag is next 
inserted upon the left side and the blades dilated so as to 
open the jaws widely, and as the gag is self -retaining, this 
position is easily maintained. The jaws being thus held open, 
the operator, sitting on a chair facing the patient (Fig. 416) , 

Fig. 416. 




Intubation of the larynx. 

next introduces the index finger of the left hand, protected by 
a strip of adhesive plaster or a metal shield, into the mouth 
and passes it over the tongue until he feels the epiglottis. 
The introducing instrument, to which the tube is attached, is 
held in the right hand and introduced into the mouth after 
observing that the silken loop is free; it is swept over the 
tongue and passed down until it touches the epiglottis; this 



OPERATION OF INTUBATION OF THE LARYNX 593 

is hooked up by the index finger of the left hand and the 
tube passed into the larynx; the index finger of the left hand 
is then transferred to the edge of the tube, and by pressing 
upon the trigger of the instrument with the thumb of the 
right hand the obturator is detached and the instrument is 
withdrawn, and before removing the finger it is well to place 
it upon the head of the tube and to sink it well into the 
larynx. As soon as the obturator is removed there is usually 
a violent expiratory effort, which is accompanied by a gush 
of mucus, mucopurulent matter, or membrane from the tube, 
and after this escapes the breathing is usually satisfactorily 
established. If the operator has passed the tube into the 
esophagus and has detached it from the introducing instru- 
ment, no improvement in the respiration takes place; it 
should then be withdrawn by the silk loop attached to the 
tube, and another attempt made to introduce it into the 
larynx. 

The mistake which inexperienced operators make in 
attempting to introduce the tube is in not hugging the 
posterior surface of the tongue closely, thereby passing the 
tube over the epiglottis into the esophagus. 

The silken loop may be brought out at one side of the 
mouth and adjusted around the ear or fastened to the side 
of the face by strips of adhesive plaster for a few hours, so 
that by drawing upon it the nurse or attendant can withdraw 
the tube instantly if it should become obstructed with mem- 
brane; or, if it is coughed up, by this means it may be with- 
drawn from the esophagus if it has not been expelled from 
the mouth. Some operators keep the loop attached to the 
tube during the time it is retained in the larynx. I prefer 
to remove it after the tube is securely placed in the larynx, 
and to withdraw the tube by means of the extracting instru- 
ment when required. 

Extubation or the removal of the tube is, as a rule, more 
difficult than its introduction. This is done with the patient 
either in the sitting position or prone; the jaws are held open 
by the mouth gag and the operator passes his finger into 
the mouth and locates the epiglottis and head of the tube; 
the extracting instrument is next introduced and the closed 
38 



594 



OPERATIONS 



blades are passed into the opening in the tube and the blades 
expanded and the instrument withdrawn with the tube 
attached. If there is difficulty in grasping the tube it may 
be loosened and pushed upward by pressure and manipula- 
tion on the neck over the upper part of the trachea and 
larynx, and when it protrudes from the larynx it may be 

Fig. 417. 




Feeding a case of intubation of the larynx. 



grasped with forceps and removed. The tube should be 
removed at the end of the second or third day, and if the 
child can breathe comfortably for an hour or two it need not 
be reintroduced; if, however, the dyspnea returns, it should 
be reintroduced and allowed to remain one or two days longer; 
several attempts may have to be made before the tube can 



FEEDING AFTER INTUBATION 595 

be permanently removed; it is usually dispensed with from 
the third to the eighth day. 

The most serious complication which is apt to occur during 
the introduction of the intubation tube is the detachment 
and pushing of a mass of membrane in front of the tube into 
the trachea; if the mass is too large to be expelled through 
the tube the breathing is suddenly arrested. The tube should 
be removed at once, and if the mass of membrane does not 
escape with the expiratory efforts of the patient the trachea 
should be rapidly opened as the only means of reestablishing 
the respiratory function. So much do I dread this accident, 
which has occurred in a few cases, that I never introduce the 
intubation tube without having at hand the necessary instru- 
ments to do a tracheotomy if it should be suddenly required, 
and, if possible, obtain the consent of the parents or friends 
to perform tracheotomy if it should be indicated. 

Feeding after Intubation.— One of the greatest difficulties 
after intubation of the larynx is the satisfactory feeding of 
the patient; liquids, as a rule, are not swallowed well, a por- 
tion escaping into the tube, causing coughing and difficulty 
in breathing. The diet I usually prefer is semisolid, such as 
cornstarch, soft-boiled eggs and mush; and if these are not 
well swallowed it may be necessary to resort to nutritious 
enemata or the use of a stomach tube to introduce food. 
Some patients swallow liquids and semisolids quite well if 
the head is placed a little lower than the body during the act 
of deglutition (Fig. 417). 



PART VII. 
LIGATION OF ARTERIES. 



In the application of a ligature to an artery in its con- 
tinuity the surgeon should make his incision in the line 
which corresponds to the general course of the vessel, and 
he should be thoroughly familiar with the anatomy and 
with the surgical landmarks of the part. A portion of 
the artery, when possible, should be selected for the appli- 
cation of the ligature half an inch or an inch from any 
large collateral branch. The position of the incision being 
selected, the surgeon steadies the skin with two fingers and 
makes an incision of the required length through it with a 
scalpel; the superficial fascia is next picked up on a director, 
any large superficial veins which come into view being dis- 
placed, and divided to an equal length with the incision in 
the skin; the deep fascia being exposed, it should be nicked 
and divided upon a director; the intermuscular space, or the 
edge of the muscle or muscles which are the guide to the 
vessel, should next be sought for, and small arteries coming 
from the main vessel through these spaces will often serve 
as valuable guides to the position of the artery. The surgeon 
next separates the tissues with the director or handle of the 
knife until the sheath of the vessel is exposed; this is recog- 
nized by its communicated pulsation and by the absence of 
the smooth, shining surface and pinkish-white color which 
the surface of the artery presents. The sheath of the artery 
should be picked up with forceps and nicked with the point 
of the knife applied flatwise (Fig. 419, A); the incision into 
the sheath should be very limited, only sufficiently large to 



598 



LIGATION OF ARTERIES 



allow the aneurysm needle to pass through it around the 
vessel; extensive dissections or separations of the sheath 
from the artery should be avoided, as the nutrition of the 
artery at the point of ligature may thus be impaired, and 
sloughing and secondary hemorrhage may result. A distinct 
sheath is found only about the main arterial trunks, which is 
replaced in the smaller artery by a layer of loose cellular 
tissue. The wall of the artery being exposed, an aneurysm 



Fig. 418. 



Fig. 419. 




Aneurysm 
needle. 



A, opening sheath; B, passing ligature around 
the vessel; C, ty.ng the artery. 



needle (Fig. 418) is passed around the vessel, threaded with 
a catgut ligature, and withdrawn (Fig. 419, B) ; the needle 
may be threaded before being passed, in which case the liga- 
ture is grasped with forceps and drawn through while the 
needle is withdrawn. The best material for ligatures is silk 
or carefully prepared chromicized catgut. The needle should 
be passed away from important structures, such as accom- 
panying veins and nerves. 

Before the ligature is tied the surgeon should satisfy him- 



LIGATION OF SPECIAL ARTERIES 



599 



self that the ligature when tied will control the circulation in 
the artery below its point of application, by placing the tip 
of his finger upon the vessel and drawing upon the ends of 
the ligature, so as to occlude the vessel at the point of appli- 
cation. Being satisfied as to this point, the ligature is tied 
with a reef knot, or a surgeon's knot and reef knot combined, 
and the ends of the ligature are cut short in the wound (Fig. 
419, C). 

Some authorities recommended the application of two liga- 
tures a short distance apart in the ligation of vessels in their 
continuity, and a division of the vessel between them, so 
that both ends may retract into the cellular sheath. 

Fig. 420. 




Lines of incision for — A, innominate artery; B, right subclavian artery; C, left 
subclavian artery; D, vertebral or inferior thyroid artery; E, axillary artery below 
clavicle. 



Ligation of Special Arteries. — Ligation of the Innominate 
Artery.— The innominate artery lies immediately behind the 
sternoclavicular articulation, and is in relation in front with 
the innominate veins and pneumogastric nerve, on the inner 
side with the trachea, on the outer side and behind with the 
pleura. 

The incision is a V-shaped incision, each branch of which 
is 2\ or 3 inches in length, one of which lies over the anterior 



600 LIGATION OF ARTERIES 

edge of the sternocleidomastoid muscle and the other parallel 
to and a little above the clavicle (Fig. 420, A). The inci- 
sions are carried down to the superficial fascia and a flap 
is dissected up. If the anterior jugular vein is met with it 
should be displaced. The sternal and clavicular attach- 
ments of the sternocleidomastoid are next divided upon a 
director § inch above the bone. The sternothyroid and 
sternohyoid muscles and the middle cervical fascia are then 
exposed, covered by the thyroid veins. The outer fibers of 
the sternohyoid and sternothyroid muscles are next divided, 
the thyroid vein being held aside, when upon tearing through 
the fascia with a director the common carotid artery is 
exposed and traced down to the innominate artery; the 
innominate veins are pressed against the sternum with the 
finger, and the artery is separated from its sheath about \ 
inch below its bifurcation, and the aneurysm needle is passed 
around the vessel from the outer side, so as to avoid the 
vein, pneumogastric nerve and pleura. 

Ligation of the Subclavian Artery. — This artery may be tied 
at three points; in its first portion, between the trachea and 
scaleni muscles ; in its second portion, behind the scaleni mus- 
cles; and in its third portion, external to the scaleni muscles. 

The left subclavian artery in its first portion is larger and 
more vertical in its direction than the right subclavian, and 
is situated more posteriorly. From the difficulty in exposing 
this portion, and from the possibility of injuring the thoracic 
duct, the ligation of this artery in its first portion has been 
seldom attempted. 

The incision for the first portion of the subclavian artery is 
the same as that for the innominate (Fig. 420, A), and the 
ligature is passed from the outer side, the pneumogastric 
and phrenic nerves being pressed inward toward the carotid 
artery. 

The right and left subclavian arteries are also seldom tied 
in their second portions — that is, behind the scaleni muscles 
— but are frequently tied in their third portions — that is, 
external to the scaleni muscles. 

The incision for the second portion of the subclavian artery 
begins an inch external to the sternoclavicular articulation, 



LIGATION OF THE SUBCLAVIAN ARTERY 



601 



J inch above and parallel to the clavicle, and is 3 or 4 inches 
in length (Fig. 420, B or C) . The steps of the operation are 
the same as for ligation of the third portion, and when the 
scalenus anticus muscle has been exposed it is divided upon 
a director; the phrenic nerve, which lies upon its anterior 
aspect, is to be avoided. 

Fig. 421. 




Ligation of subclavian and lingual arteries. 

The incision for the third portion of the subclavian artery 
is the same as for the second portion (Fig. 420, B or C). The 
skin and platysma being divided, the external jugular vein 
is exposed and drawn to one side or divided between two 
ligatures; the superficial fascia is next divided upon a director; 
the posterior belly of the omohyoid muscle is next found and 
drawn upward and outward; the outer border of the scalenus 



602 LIGATION OF ARTERIES 

anticus is next felt for and followed down to the tubercle of 
the first rib — the artery lies against this, between it and the 
lowest bundle of the brachial plexus. The artery is next 
denuded with the director, and the needle is passed from 
below, care being taken not to include the lowest bundle of 
the brachial plexus in the ligature (Fig. 421). 

Ligation of the Vertebral Artery.— The incision for the liga- 
tion of the vertebral artery is 3 or 3J inches in length, parallel 
with the anterior edge of the sternocleidomastoid muscle, 
ending 1 inch above the clavicle (Fig. 420, D). The anterior 
edge of the sternocleidomastoid being exposed, the middle 
cervical fascia is divided and the carotid artery and jugular 
vein are exposed and drawn inward. The gap between the 
longus colli muscle and the scalenus anticus muscle is next 
felt for about 1 inch below the carotid tubercle; the fascia 
covering it is next torn through and the muscles are separated 
and the vertebral vein comes into view. When this vein is 
held aside the vertebral artery is exposed and the ligature is 
then passed around it. 

Ligation of the Inferior Thyroid Artery. — The incision for the 
inferior thyroid artery is the same as that for the vertebral 
artery (Fig. 420, D) . The anterior edge of the sternocleido- 
mastoid muscle being exposed, it is drawn outward, the mid- 
dle cervical fascia is next divided, and the carotid artery and 
internal jugular vein are drawn outward with a retractor. 
The head being flexed slightly, the surgeon feels for the caro- 
tid tubercle, and then separates the cellular tissue with a 
director, and the artery should be found below the carotid 
tubercle. The needle should be passed between the artery 
and vein. 

Ligation of the Internal Mammary Artery. — The incision, a 
vertical one, 2| inches in length, commences at the lower 
border of the clavicle, parallel with and three lines external 
to the margin of the sternum. Divide the skin and superficial 
fascia and expose the fibers of the great pectoral muscle, the 
external intercostal aponeurosis, and the muscular fibers of 
the internal intercostal muscle. Raise the fasciculi of the 
latter muscle upon a director and divide them, and the 
vessel will be exposed. The internal mammary artery is 
not often tied below the fourth intercostal space. 



LIGATION OF THE COMMON CAROTID ARTERY 603 

Ligation of the Common Carotid Artery . — The point of elec- 
tion for the ligation of the common carotid artery is just 
above the omohyoid muscle, about f inch below the bifurca- 
tion of the vessel, which takes place at a point on a line with 
the upper border of the thyroid cartilage. 

The incision for the common carotid artery is 3 inches in 
length along the anterior border of the sternocleidomastoid 
muscle, the center of which corresponds with the cricothyroid 
space (Fig. 422). 

Fig. 422. 




Line of incision for common carotid artery at point of election. 

Divide the skin, platysma, cellular tissue and aponeurosis, 
avoiding the superficial veins and expose the anterior edge 
of the sternocleidomastoid ; seek for the interspace between 
this muscle and the sternohyoid and sternothyroid muscles, 
draw the latter muscles inward, and the artery will be exposed 
with the jugular vein external to it; the descendens noni 
nerve lying upon its sheath should be displaced outward. 
The sheath is next picked up and opened and the artery is 
separated from it with a director; the artery lies internally, 
the internal jugular vein externally and somewhat more 
superficial, and the pneumogastric nerve lies between the two, 
and is more deeply placed. The sympathetic nerve is poste- 
rior to the vessel external to the sheath. The needle is passed 
from without inward, care being taken to avoid injury of the 
vein and nerve (Fig. 423). 



604 



LIGATION OF ARTERIES 



Ligation of the External Carotid Artery. — The incision for the 
ligation of the external carotid artery is over the inner edge 
of the sternocleidomastoid muscle from the angle of the jaw 



Fig. 423. 




Relations of the left common carotid artery above the omohyoid muscle. 

Fig. 424. 




Lines of incision for — A, lingual artery; B, external and internal carotid arteries; 
C, occipital artery; D, temporal artery; E, facial artery. 



LIGATION OF THE LINGUAL ARTERY 



605 



Fig. 425. 



to a point corresponding to the middle of the thyroid cartilage 
(Fig. 424, B). The skin, platysma and cellular tissue being 
divided, the external jugular vein is drawn aside when 
encountered; the deep fascia being opened, the facial and 
lingual veins will be exposed, which should be drawn to one 
side; the artery is next exposed, covered by the hypoglossal 
nerve and the stylohyoid and digastric muscles. The vessel 
should next be isolated from the internal carotid artery and 
internal jugular veins, both of which lie along its outer side. 
The needle should be passed from without inward. 

Ligation of the Internal Carotid Artery. — The incision is the 
same as for the external carotid artery (Fig. 424, B); the 
vessel is external to the external carotid artery, and in passing 
the needle the point should be directed away from the internal 
jugular vein — that is, from without inward. 

Ligation of the Superior Thyroid Artery.— The incision is 
about 3 inches in length along the anterior border of the 
sternocleidomastoid muscle, 
starting a little lower down 
than that for the external 
carotid artery. The skin, 
superficial fascia, platysma 
and deep fascia being divi- 
ded, the cellular tissue in the 
sulcus between the upper por- 
tion of the larynx and the 
great vessels of the neck should 
be broken up with the director 
and the vessel exposed. The 
needle should be passed 
around the vessel from above 
downward. 

Ligation of the Lingual Artery. — The incision is a curved one 
2 inches long, its concavity directed upward from the anterior 
edge of the sternocleidomastoid muscle, J inch above the 
great horn of the hyoid bone, to a point 1 inch within the 
median line of the neck (Fig. 424, A). Divide the skin and 
platysma, displacing the superficial veins, and open the deep 
fascia, when the submaxillary gland will be exposed; this is 




Relations of the lingual artery. 



606 



LIGATION OF ARTERIES 



displaced upward with the handle of the knife, when the 
tendon of the digastric muscle attached to the hyoid bone, 
and the hypoglossal nerve will be exposed; next divide the 
fibers of the hyoglossus muscle midway between the hypo- 
glossal nerve and the hyoid bone, and the lingual artery will 
be exposed (Fig. 425) . The needle should be passed around 
the vessel from above downward in order to avoid the nerve. 

Ligation of the Facial Artery. — The facial artery passes over 
the inferior maxilla just in front of the anterior edge of the 
masseter muscle, and is accompanied by the facial vein, which 
lies nearer to the muscle. 

The incision is either a horizontal one along the lower 
border of the maxilla or a vertical 1 inch in length (Fig. 
424, E). The skin, subcutaneous tissue and fascia being 
divided, the artery is exposed; the needle should be passed 
around the vessel away from the vein. 



Fig. 426. 



Fig. 427. 





Ligation of the occipital artery. 



Ligation of the temporal artery. 



Ligation of the Occipital Artery. — The incision is 2 inches in 
length, starting from a point J inch below and in front of 
the apex of the mastoid process, and carried obliquely back- 
ward, parallel to the border of this process (Fig. 424, C). 
Divide the skin and fascia and expose the insertion of the 
sternocleidomastoid muscle, which is also divided, and the 
aponeurosis of the splenius is exposed; this is also opened 
and the digastric groove is felt for, and when the belly of the 



LIGATION OF THE AXILLARY ARTERY 607 

digastric muscle is exposed the artery is brought into view by 
separating the cellular tissue in the anterior angle of the 
wound with a director (Fig. 426) . 

Ligation of the Temporal Artery. — The incision is transverse 
one, 1 inch in length, starting from the tragus of the ear 
forward over the zygomatic arch (Fig. 424, D), or a vertical 
one of the same length a little in front of the tragus of the ear. 

Divide the skin and expose the subcutaneous cellular tissue, 
which in this region is very dense and fibrous. This tissue 
should be broken up with a director, and the artery should be 
found in it about J inch in front of the ear (Fig. 427) . The 
temporal vein accompanies the artery and lies nearer to the 
ear, and in some cases the auriculotemporal nerve is in close 
relation to the artery. The needle should be passed from 
behind forward. 

Ligation of the Axillary Artery. — The axillary artery extends 
from the middle of the clavicle to the insertion of the teres 
major into the humerus; the axillary vein lies upon the inner 
side and in front of the artery. The axillary artery is tied 
either in its upper portion, just below the clavicle, or at its 
lower portion in the axilla. 

Axillary Artery below the Clavicle. — The incision is 4 inches 
in length from the summit of the coracoid process inward a 
short distance below the clavicle (Fig. 420, E), or an incision 
3 inches in length, commencing at a point \ inch from the 
sternoclavicular articulation and carried obliquely down- 
ward toward the axilla. 

The skin and subcutaneous tissue having been divided, the 
deep fascia is exposed and opened, and the axillary artery 
may be reached by following the intermuscular space between 
the sternal and clavicular fibers of the pectoralis major which 
leads upward toward the clavicle and to the pectoralis minor; 
or the fibers of the pectoralis major being exposed, are cut 
through and the costocoracoid membrane is next torn 
through with a director, care being taken to avoid injury of 
the cephalic vein at the outer portion of the wound; the 
pectoralis minor is now seen, and after separating the cellular 
tissue with a director the axillary vein is seen crossing from 
the upper edge of the muscle to the clavicle; the vein almost 



608 



LIGATION OF ARTERIES 



completely covers the artery, which is exposed by drawing 
the vein inward. The needle is passed around the artery 
from within outward. 

Fig. 428. 




A, incision for axillary artery in axilla; B, incision for brachial artery. 

Axillary Artery in the Axilla. — The incision is 2 inches 
long, started at the upper part of the axilla and carried down 



Fig. 429. 




Relations of right axillary artery in axilla. 

the arm at the edge of the coracobrachialis muscle (Fig. 
428, A). The skin only is divided in the first incision. The 
deep fascia is then picked up and divided upon a director. 



LIGATION OF THE BRACHIAL ARTERY 



609 



As soon as the fibers of the inner border of the coraco- 
brachial muscle are exposed and held aside by a retractor, 
the operator will see the median nerve, the musculocutane- 
ous nerve, and the axillary artery. To the inner side of the 
artery are the axillary vein, ulnar and internal cutaneous 
nerves (Fig. 429). The needle should be passed around the 
artery from the vein toward the coracobrachialis muscle. 

Ligation of the Brachial Artery. — The incision is 3 inches 
long at the middle of the arm, on a line corresponding to the 
inner edge of the biceps muscle (Fig. 428, B) . The skin and 
cellular tissue having been divided, care being taken not to 

Fig. 430. 




Relations of right brachial artery at middle of arm. 



injure the basilic vein, which should be displaced posteriorly, 
the deep fascia is next cut through and the fibers of the biceps 
muscle are exposed (Fig. 430) ; this muscle should be drawn 
forward and the sheath of the vessels enclosing the artery, 
veins and median nerve exposed; the sheath having been 
opened, the median nerve is pressed aside and the artery is 
separated from its veins, and the needle is passed from the 
side of the nerve around the vessel. In ligating the brachial 
artery the occasional high division of the vessel must be 
borne in mind. 

Brachial Artery at Bend of the Elbow. — The incision is 2 
inches in length, along the inner border of the tendon of the 
39 



610 LIGATION OF ARTERIES 

biceps muscle. Divide the skin, superficial fascia and the 
bicipital aponeurosis, under which the artery will be exposed, 
resting upon the brachialis anticus muscle (Fig. 431). The 
median nerve is to the inner side and some distance from the 
artery. The needle should be passed around the vessel, after 
isolating the veins, from within outward. 

Fig. 431. 

Tendinous aponeurosis 
divided. 




Ligation of the brachial artery at the bend of the elbow. 

Ligation of the Radial Artery. — The radial artery extends in 
a straight line from a point \ inch below the center of the fold 
of the elbow to the inner side of the styloid process of the 
radius. 

The radial artery may be tied at its upper, middle or lower 
third, or at the root of the thumb. 

Radial Artery in the Upper Third of the Forearm. — The 
incision for the radial artery at its upper third is 2 J inches in 
length on a line drawn from the middle of the bend of the 
elbow to the ulnar side of the styloid process of the radius; 
the incision should begin 1J inches below the bend of the 
elbow (Fig. 432, A). Divide the skin and superficial fascia, 
avoiding the superficial veins. When the deep fascia is 
exposed, find the edge of the supinator longus muscle and 
divide the aponeurosis along its ulnar side, and expose the 
fibers of the pronator radii teres muscle. The vessel lies in 
the interspace between these muscles surrounded by adipose 
tissue, and upon being exposed the veins should be isolated 



LIGATION OF THE RADIAL ARTERY 



611 



and the needle passed from without inward. The radial 
nerve lies so far external to the artery that it is not often 
exposed in the operation (Fig. 433) . 

Radial Artery in the Middle Third of the Forearm. — The 
incision is 2 inches in length, following the same line as that 



Fig. 432. 



Fig. 433. 




Relations of right radial artery in the 
upper third of the forearm. 

Fig. 434. 



D% 



-k-JB 



%\ 



Line of incision for — A, radial artery 
in upper third; B, radial artery in lower 
third; C, ulnar arterj in upper third; D, 
ulnar artery in lower third. 




Relations of right radial artery above 
the wrist. 



for the upper third of the artery. After dividing the skin, 
superficial and deep fascia, the artery is found in the inter- 
space between the flexor carpi radialis on the inner side and 
the supinator longus on the outer side; the radial nerve at 
this part of the arm is in close relation with the vessel to the 



612 LIGATION OF ARTERIES 

radial side, and the needle should be passed around the artery 
from without inward. 

Radial Artery in the Lower Third of the Forearm. — The 
incision is 2 inches in length, following the same line (Fig. 
432, B), ending 1 inch above the wrist. The skin, superficial 
and deep fascia being divided, the artery will be found 
between the tendon of the flexor carpi radialis on the inner 
side and the tendon of the supinator longus on the outer side 
(Fig. 434). The veins being separated, the needle may be 
passed in either direction. 

Radial Artery at the Root of the Thumb. — The radial artery 
may also be tied at the root of the thumb. The incision is 
1 inch in length between the tendons of the extensor ossis 
metacarpi pollicis and extensor primi internodii pollicis on 
the outer side, and the tendon of the extensor secundi inter- 
nodii pollicis on the inner side. The skin and superficial 
fascia being divided and the radial vein being displaced, the 
deep fascia is opened and the artery is exposed at the bottom 
of the wound; the needle may be passed in either direction. 

Ligation of the Ulnar Artery. — The ulnar artery is tied at the 
junction of the upper and middle thirds of the forearm and at 
the lower third. 

Ulnar Artery at the Junction of the Upper and Middle 
Thirds of the Forearm. — The incision is 3 inches in length, 
starting 4 inches below the internal condyle of the humerus 
on a line passing from the internal condyle of the humerus to 
the outer border of the pisiform bone (Fig. 432, C). Divide 
the skin and superficial fascia, and when the deep fascia has 
been exposed and the interspace between the flexor carpi 
ulnaris and the flexor sublimis digitorum appears, enter this 
interspace and raise the flexor sublimis digitorum and work 
transversely across the arm. The artery will be found resting 
upon the deep flexor, with the ulnar nerve to the ulnar side. 
The needle should be passed from the nerve around the 
artery (Fig. 435). 

Ulnar Artery in the Lower Third of the Forearm. — The inci- 
sion is 2 inches in length, a little to the radial side of the 
tendon of the flexor carpi ulnaris, which is attached to the 
pisiform bone, ending 1 inch above the wrist (Fig. 432, • D) . 



LIGATION OF THE ABDOMINAL AORTA 



613 



Divide the skin and superficial fascia and open the deep 
fascia; the artery will be exposed with its accompanying 
veins, between the tendons of the flexor carpi ulnaris and 
flexor sublimis digitorum, the ulnar nerve being to the ulnar 
side of the vessel. The needle should be passed from within 
outward to avoid the nerve (Fig. 436). 



Fig. 435. 



Fig. 436. 





Relations of the right ulnar artery of upper 
third of the forearm. 



Relations of the right ulnar artery 
above the wrist. 



Ligation of the Interosseous Artery.— The incision is similar 
to that employed in the ligation of the ulnar artery in its 
upper third. 

Ligation of the Abdominal Aorta. — The incision is in the 
linea alba from a point 3 inches above the umbilicus to a 
point 3 inches below it. The superficial structures being 
divided, the peritoneum is opened upon a director, and the 
intestines are pressed aside and the aorta is exposed, covered 
by peritoneum, with the filaments of the sympathetic nerve 
resting upon it and the vena cava to the right side. Tear 
through the peritoneum and pass the needle from right to 
left around the vessel. After tying the ligature the ends 
should be cut short and the external wound should be closed 
as in the ordinary laparotomy wound. 

The vessel may also be exposed by an incision along the 
anterior border of the quadratus lumborum muscle, from the 



614 



LIGATION OF ARTERIES 



last rib to the crest of the ilium. The skin, lumbar muscles 
and fascia transversalis being divided, the wound is held 
open with blunt hooks, so that the retroperitoneal space is 
exposed and the aorta brought into view. The vessel being 
separated from the vena cava and nerves, the needle is passed 
around it and the ligature applied. 

Ligation of the Common Iliac Artery. — The aorta divides into 
the two common iliac arteries on the left side of the fourth 
lumbar vertebra, and these arteries are usually about 2 inches 
in length, and bifurcate opposite the sacroiliac synchondro- 
sis to form the internal and external iliac arteries; the length 
of the common iliac artery, however, may vary considerably, 
being 3 or 4 inches in some cases. 

Fig. 437. 




Lines of incision for — A, common iliac artery; B, external iliac artery; C, femoral 
artery in Scarpa's triangle. 



The incision for ligation of the common iliac artery is 4 to 
6 inches in length, beginning \ inch above the middle of 
Poupart's ligament, and is carried outward, curving upward 
after passing the anterior-superior spine of the ilium (Fig. 
437, A). 

Divide the skin, superficial fascia and aponeurosis of the 
external oblique muscle, and then divide the fibers of the 
internal oblique and transversalis muscles upon a director 
and expose the transversalis fascia. This is opened at the 



LIGATION OF THE INTERNAL ILIAC ARTERY 615 

lower part of the wound, and the finger is introduced and the 
peritoneum pressed back; the opening in the transversalis 
fascia is next enlarged, and the peritoneum is carefully drawn 
inward and upward with the fingers toward the inner edge 
of the wound. The operator next feels for the external iliac 
artery, and passes the finger along this until the common iliac 
artery is reached. The loose cellular tissue in which it is 
imbedded is next separated, and the needle is passed from 
within outward, to avoid the common iliac vein (Fig. 438), 
which on the left side lies on the inner side of the artery, and 
on the right side lies behind the artery. The ureter generally 
remains attached to the peritoneum ; if not, it is seen crossing 
the bifurcation of the common iliac with the genitocrural 
nerve; care should be taken to avoid injury of these structures 

Transperitoneal Method. — The common iliac artery may 
also be exposed and tied by an incision made over the artery 
through the abdominal wall opening the peritoneal cavity; 
the vessel being tied, the ends of the ligature are cut short, 
and the external wound is closed in the same manner as that 
resulting from exposure of the abdominal aorta by incision 
through the peritoneum. 

Ligation of the Internal Iliac Artery. — The incision is in the 
same line as for the common iliac artery, but it need not be 
quite so long (Fig. 437, A). The peritoneum being exposed, 
it is pushed upward and inward, and the internal iliac artery 
is exposed. The vessel is carefully isolated from the vein, 
which lies behind and on the inner side, and the needle is 
passed from within outward. 

The transperitoneal method may also be employed in 
exposing and ligating this vessel. 

Ligation of the External Iliac Artery. — The incision is 3 or 4 
inches in length, \ inch above the middle of Poupart's liga- 
ment, made at first parallel to it and then curved upward 
(Fig. 437, B). The tissues of the abdominal wall being 
divided and the peritoneum exposed, it is pushed upward and 
inward in the same manner as for exposure of the common 
iliac artery. The artery lies at the inner border of the psoas 
muscle, the vein on its inner side and the anterior crural nerve 
covered by the iliac fascia on the outer side; the genitocrural 



616 



LIGATION OF ARTERIES 



nerve passes obliquely across the artery (Fig. 439). The 
needle should be passed from within outward. 



Fig. 438. 




Ligation of the common iliac artery. 
Fig. 439. 




Relations of the right external iliac artery. 



SCIATIC AND INTERNAL PUDIC ARTERIES 617 

The transperitoneal method may also be employed in ligat- 
ing this vessel. 

Ligation of the Gluteal Artery. — The incision is 3 or 4 inches 
in length, from the posterior-superior spinous process of the 
ilium to a point midway between the tuber ischii and the 
great trochanter (Fig. 440, A). After division of the skin 
and fascia the fibers of the gluteus maximus muscle are sepa- 
rated and held apart, the deep fascia is divided and the artery 
should then be sought for above the pyriformis muscle at the 
upper border of the great sacrosciatic notch. It is accom- 
panied by large veins, injury to which should be avoided in 
exposing the artery and passing the needle. 

Fig. 440. 




Lines for — A, gluteal artery; B, sciatic and internal pudic arteries. 



Ligation of the Sciatic and Internal Pudic Arteries. — The inci- 
sion is 3 or 4 inches in length, a little lower than that employed 
for exposure of the gluteal artery (Fig. 440, B). Divide the 
skin, superficial fascia and fibers of the gluteus maximus mus- 
cle and deep fascia, and search for the vessels as they leave the 
great sciatic notch at the lower edge of the pyriformis muscle. 
The internal pudic artery enters the pelvis through the lesser 



618 



LIGATION OF ARTERIES 



sciatic notch, lying on the inner side of the sciatic artery dur- 
ing its passage over the spine of the ischium. The vessels are 
isolated and the needle is passed so as to avoid injury of the 
veins. 

Ligation of the Femoral Artery.— The femoral artery may be 
ligated just below Poupart's ligament, at the apex of Scarpa's 
triangle, at the middle of the thigh or in Hunter's canal. 

Femoral Artery below Poupart's Ligament. — The incision 
begins midway between the anterior-superior spinous process 
of the ilium and the symphysis pubis, \ inch above Poupart's 



Fig. 441. 




Relations of the right femoral artery below Poupart's ligament. 

ligament, and extends 2 inches downward. Divide the skin 
and superficial fascia and the deep fascia so as to expose the 
sheath of the vessels; open this \ inch below Poupart's liga- 
ment and isolate the femoral artery from the femoral vein 
which lies to the inner side; the anterior crural nerve lies 
to the outer side. Pass the needle from within outward 
(Fig. 441). 

Femoral Artery at the Apex of Scarpa's Triangle. — The inci- 
sion is 3 inches long, the center of which should be a little 
above the point where the sartorius muscle crosses a line 



LIGATION OF THE FEMORAL ARTERY 619 

drawn from the middle of Poupart's ligament to the inner 
condyle of the femur (Fig. 442). Divide the skin, superficial 
and deep fascia, avoiding the internal saphenous vein, and 
expose the edge of the sartorius muscle, which may be recog- 
nized by the direction of its fibers. This muscle is drawn 
outward and the sheath of the vessels is exposed and opened; 
the vein lies on the inner side and somewhat behind the 
artery, and the long saphenous nerve is on the outer side 
(Fig. 443). Pass the needle from within outward. 



Fig. 442. 






Lines of incision for the femoral artery. 

Femoral Artery in the Middle of the Thigh. — The incision is 
in the line above mentioned, its center being a little above the 
middle of the thigh. Divide the skin, superficial and deep 
fascia, and expose the sartorius muscle, which is drawn out- 
ward after the leg has been flexed; the sheath of thei vessels 
is exposed and opened; the long saphenous nerve lees upon 
the artery and the femoral vein lies behind the art ry; the 
saphenous vein lies more superficially and internal to the 
vessel. Pass the needle from within outward (Fig. 444). 

Femoral Artery in Hunter's Canal. — The incision is 3 
inches in length along the tendon of the adductor magnus, 
the center of which is at the junction of the lower and middle 
thirds of the thigh (Fig. 442). Divide the skin, superficial 
and deep fascia, care being taken not to injure the internal 
saphenous vein, which should be displaced, and expose the 



620 



LIGATION OF ARTERIES 



sartorius muscle, which should be displaced downward, and 
expose the aponeurosis which forms the anterior wall of the 
vascular canal; this should be opened upon a director, and 
the artery uncovered and separated from the vein which lies 
upon the outer side. The needle is passed from within 
outward. 



Fig. 443. 



Fig. 444. 





Relations of the right femoral artery 
at the apex of Scarpa's triangle. 



Relations of the right femoral artery 
in the middle of the thigh. 



Ligation of the Popliteal Artery.— The incision is 3 or 4 inches 
in length, along the external border of the semimembranosus 
muscle. Divide the skin and superficial fascia, taking care 
not to injure the saphenous veins, and open the deep fascia. 
The edges of the wound being held apart, the adipose tissue 
is broken up with a director, and the internal popliteal nerve 
will first be exposed, and the vein next — both external to the 
artery (Fig. 445). The artery is isolated and the needle 
passed from without inward. 

Ligation of the Anterior Tibial Artery. — The anterior tibial 
artery may be tied in the upper, middle and lower thirds 
of the leg; the general direction of the artery corresponds 
with a line drawn from the middle of the space between the 
head of the fibula and the tubercle of the tibia to the middle 
of the anterior intermalleolar space. 



LIGATION OF THE ANTERIOR TIBIAL ARTERY 621 



Anterior Tibial Artery in the Upper Third of the Leg. — The 
incision is 2\ to 3 inches in length 1J inches external to the 
spine of the tibia. Divide the skin and superficial fascia, and 
when the deep fascia is exposed open it on a line correspond- 
ing to the intermuscular space between the tibialis anticus 
and the extensor longus digitorum muscles. Separate the 
muscles and work down in this interspace until the artery is 
found with a vein on either side of it, and the anterior tibial 
nerve externally (Fig. 446). The needle should be passed 
from without inward after isolating the veins. 



Fig. 445. 



Fig. 446. 





Relations of the right popliteal artery. 



Ligation of the anterior tibial artery 
at its upper third. 



Anterior Tibial Artery at its Middle Third. — The incision is 
3 inches in length in the same line as that for the upper por- 
tion of the vessel. After dividing the skin, superficial and 
deep fascia, the interspace between the tibialis anticus and 
the extensor longus digitorum muscles is opened, when a 
third muscle comes into view, the extensor proprius pollicis. 
The artery lies between the extensor proprius pollicis and the 
tibialis anticus muscles; and the anterior tibial nerve is to the 



622 LIGATION OF ARTERIES 

outer side. The veins should be isolated and the needle 
passed from without inward. 

Anterior Tibial Artery in its Lower Third. — The incision is 
2 inches in length, beginning 3 inches above the ankle-joint 
on the line of the artery. Divide the skin, superficial and 
deep fascia, and seek for the tendon of the extensor proprius 
pollicis muscle, the second tendon from the tibia. The 
artery is found in the interspace between this tendon and the 
tendon of the extensor longus digitorum muscle, the nerve 
being to the outer side. The veins are isolated from the 
artery and the needle is passed from without inward. 

Ligation of the Dorsalis Pedis Artery. — The incision is 1 inch 
in length on a line drawn from the middle of the anterior inter- 
malleolar space to a point midway between the extremities of 
the first two metatarsal bones or along the outer border of the 
tendon of the extensor proprius pollicis. Divide the skin, 
superficial and deep fascia, and the artery will be found lying 
next to the inner tendon of the short extensor muscle of the 
toes (Fig. 447). The nerve is to the outer side. After sepa- 
rating the veins the needle is passed from without inward. 

Ligation of the Posterior Tibial Artery. — The course of the 
posterior tibial artery is indicated by a line drawn from the 
middle of the popliteal space to a point midway between the 
tendo Achillis and the internal malleolus of the tibia. 

The posterior tibial artery may be ligated in its upper, 
middle and lower thirds. 

Posterior Tibial Artery at its Upper Third. — The incision is 
3J inches in length, J inch from the inner edge of the tibia, 
beginning 2 inches from the upper edge of the bone (Fig. 448) . 
Divide the skin and superficial fascia, avoiding large super- 
ficial veins; next open the deep fascia and detach the origin 
of the soleus muscle from the tibia, and on raising it the under 
surface will present a white, shining sheath of tendinous 
material, beneath which will be seen a layer of fascia covering 
the tibialis posticus muscle. If search is made toward the 
middle of the leg the artery will be found covered by the inter- 
muscular fascia, the nerve being to the outer side. The 
needle is passed from without inward after the veins have 
been separated from the artery (Fig. 449). 



LIGATION OF THE POSTERIOR TIBIAL ARTERY 623 
Fig. 447. Fig. 448. 




Extensor ll 

brevis digitorum j 
muscle. 



Tendon of 
extensor 
proprius 

pollicis. 



Ligation of the dorsalis pedis artery. 

Fig. 449. 




Lines of incision for the 
posterior tibial artery. 




Relations of the right posterior tibial artery in its upper third. 



624 LIGATION OF ARTERIES 

Posterior Tibial Artery at its Middle Third.— The incision 
is 2\ inches in length, parallel with the inner edge of the tibia 
and \ inch from its border. Divide the skin, superficial and 
deep fascia, and the inner edge of the soleus will be exposed; 
press this outward, when the artery with its veins will be 
exposed also the posterior tibial nerve to the outer side. Pass 
the needle from without inward after separating the veins. 

Fig. 450. 




Ligation of the posterior tibial artery behind the inner malleolus. 

Posterior Tibial Artery behind the Inner Malleolus. — The 
incision is a curved one 2 inches in length, midway between 
the tendo-Achillis and the internal malleolus (Fig. 448). 
Divide the skin and superficial fascia, then lift the deep fascia 
upon a director and open it freely, when the artery will be 
exposed, with the tendons of the tibialis posticus and flexor 
longus digitorum muscles on the inner side and the posterior 
tibial nerve and the tendon of the flexor longus pollicis muscle 
on the outer side (Fig. 450) . After separating the veins from 
the artery the needle should be passed from without inward. 



INDEX. 



Abdomen, bandage of, many- 
tailed, 32 

Abdominal aorta, ligation of, 613 
bandage, 32 

Abscess, acute, treatment of, 299 
Hilton's method of, 300 
chronic, treatment of, 300 
palmar, treatment of, 582 
tuberculous, treatment of, 300 

Absorbent cotton, 124 

A-C-E mixture, anesthesia from, 
237 

Acetanilide, sterilization by, 407 

Acetate of aluminum, sterilization 
by, 407 

Acid-intoxication, 240 

Acidosis, 240 

Acromial end of clavicle, disloca- 
tion of, 535 

Acromion process of scapula, frac- 
ture of, 471 

Actinomyces, 392 

Active hyperemia, 199 

Actual cautery, 143 

Adrenalin, anesthesia from, 214 
chloride in hemorrhage, 283 

Agnew's splint for fracture of 
metacarpal bones, 492 
of patella, 509 

Air embolus, treatment of, 347 

Albee's method of bone transplan- 
tation in ununited fracture, 526 

Albert-Lembert suture, 269 

Allis' ether inhaler, 224 

Aluminum bronze, preparation of, 
411 

Alveolar processes, fracture of, 
456 

Ambrine dressing in burns, 328 
40 



Ambulatory treatment of fractures 
of bones of leg, 516 
of femur, 508 
Amputating saw, 561 
Amputations of fingers, 561, 562 
dressing of, 567 
through metacarpophalangeal 
articulation, 563 
of hand, dressing of, 567 
of metacarpal bones, 561, 564 
of metatarsal bones, 570 

all the metatarsal bones, 570 
fifth, 570 
of toes, 567 
all of toes, 569 
great, 569 

with its metatarsal bone, 
569 
two adjoining toes, 568 
little, 570 
Anatomical neck of humerus, frac- 
ture of, 472 
Anesthesia, epidural, 215 
general, 209, 218 

administration of, 220 
choice of anesthetic in, 218 
from A-C-E mixture, 237 
from bromide of ethyl, 237 
from C-E mixture, 236 
from chloride of ethyl, 237 
from chloroform, 232 

and oxygen, 236 
from ether, 223 

and nitrous oxide gas, 230 
and oxygen, 230 
from kelene, 237 
from nitrous oxide gas, 221 

and oxygen, 222 
from oil-ether, 231 
from scopolamine, 238 
preparation of patient for, 218 
(625) 



626 



INDEX 



Anesthesia, infiltration, 214 
intratracheal insufflation, 229 
local, 208, 209 

from adrenalin, 214 

from apothesin, 213 

from cocaine, 210 

from cold, 209 

from epinephrin, 214 

from eucaine hydrochlorate, 

212 
from holocaine hydrochlorate, 

213 
from novocaine, 212 
from procaine, 213 
from quinine-urea hydrochlo- 
ride, 213 
from rhigolene, 210 
from stovaine hydrochloride, 

213 
from sulphuric ether, 210 
from suprarenin, 214 
morphine, 238 
parasacral, 216 
pharyngeal insufflation, 228 
sacral, 215 
spinal, 216 
subarachnoid, 216 
terminal, 209, 214 
Anesthetics, 208 
after-effects of, 239 
in examination of fractures, 443 
Aneurysm needle, 598 
Ankle, dislocation of, 556 
Anoci-association, 304 
Anterior figure-of-eight bandage of 
chest, 73 
tibial artery, ligation of, 620 
at its middle third, 621 
in its lower third, 622 
in upper third of leg, 621 
Antipyrin in hemorrhages, 283 
Antisepsis, 379, 396 

in wound treatment, theory of, 
394 
Antiseptic dressings, improvised, 
418 
method of sterilization, 397 
operation, details of, 433 
poultice, 133 

treatment of infected wounds, 
436 
Antitoxins, 384 

injections of, 178 
Aorta, abdominal, ligation of, 613 



Apnea, 162 

Apothesin, anesthesia from, 213 
Approximation sutures, 254 
Aqua ammonia as rubefacient, 141 
Argyrol, sterilization by, 409 
Aristol, sterilization by, 409 
Arm and chest bandage, 71 
spiral reversed bandage of, 60 
splint, Thomas', 501 
Arsphenamine, injections of, 181 
Arterial blood, transfusion of, 157 
hemorrhage, temporary control 

of, 275 
hyperemia, 199 
Arteries, closure of, by plaster tape, 
288 
infusion of saline solution into, 

160 
ligation of, 597 
suture of, 287 

wounded, plaster tape in, 27 
rules for ligating, 289 
Arteriorrhaphy, 287 
Arteriotomy, 150 
Artificial respiration, 164 

continuous intratracheal in- 
sufflation in, 170 
Howard's method of, 165 
Laborde's method of, 168 
lung motor in, 169 
prone method of, 169 
pulmotor in, 169 
Schafer's method of, 169 
Silvester's method of, 167 
Asepsis, 379, 396 

in wound treatment, theory of, 
394 
Aseptic dressings, improvised, 418 
method of sterilization, 398 
operation, details of, 431 
preparation for, 422 

of field of operation, 424 
materials used in, 410 
of patient, 422 
of room, 424 
Asphyxia, 162 
smoke, 163 
Aspiration, 170 
Aspirator, Potain's, 170, 171 
Astragalus, dislocation of, 557 

fracture of, 518 
Autogenous vaccine, 342 
Autotransfusion of blood, 157 
Axillary artery, ligation of, 607 



INDEX 



627 



Axillary artery, ligation of, in 
axilla, 608 
below clavicle, 607 



B 



Bacillus aerogenes capsulatus, 

392 
coli communis, 389 
diphtheria, 391 
gas, 392 
influenza, 390 
tetanus, 391 
tuberculosis, 389 
typhosus, 390 
Back, strapping of, 131 
Bacteria, 379 

contamination by, 382 
infection by, 382 
pathogenic action of, 382 
putrefactive, 393 
pyogenic, 387 
of suppuration, 387 
varieties of, 387 
Bacterial vaccines, 385 
Bacteriology, surgical, 379 
Baking, application of, 195 
Bandage or Bandages, 17 
abdominal, 32 

many-tailed, 32 
arm and chest, 71 
Barton's, 43 

modified, 43 
black muslin, 100 
Borsch's, 95 
of chest, 28 
circular, 23 
compound, 27 
demi-gauntlet, 58 
Desault's, 68 
dimensions of, 20 
elastic cotton, 121 

webbing, 103 
of eyes, crossed, 52 
figure-of-eight, 26 

of chest, 73 

of elbow, 62 

of knee, 83 

of leg, 91 

of neck and axilla, 66 
flannel, 99 
of foot, American, 87 

complete, 86 



Bandage of foot, French, 88 
in fractures, 449 
gauntlet, 57 
gauze, 96 et seq. 
Gibson's, 46 
of hand, complete, 59 
handkerchief, 34 
hardening of, 104 
of head, 43 

and neck, 51 
of heel, 89 
Liebreich's, 94 
of lower extremity, 77 
lithotomy, 94 
many-tailed, 37 

of abdomen, 32 
oblique, 23 

of head, 54 

of jaw, 47 
occipitofacial, 54 
occipito-frontal, 55 
paraffine, 119 
of perineum, 92 
plaster-of-Paris, application 
106 

preparation of, 105 

removal of, 115 

trapping of, 114 
recurrent, 27 

of head, 48 

of stump, 92 

transverse, 50 
removal of, 22 
roller, 18 
rubber, 101 
scissors, 22 
of Scultetus, 95 
silicate of potassium, 118 

of sodium, 118 
spica, 26 

of buttock, 82 

of foot, 86 

of groin, ascending, 77 
descending, 79 
double, 80 
single, 77 

of shoulder, ascending, 63 
descending, 65 

of thumb, 60 
spiral, 23 

of chest, 73 

of finger, 56 

reversed, 24 
of arm, 60 



of, 



628 



INDEX 



Bandage, spiral reversed, of fing- 
ers, 57 
of leg, 89 

of lower extremity, 89 
of penis, 92 
of thigh, 90 
of upper extremity, 61 
starched, 117 
sterilization of, 419 
suspensory and compressor of 

breast, 75 
T, of groin, 29 
of trunk, 73 
of upper extremity, 56 
varieties of, 23 
Velpeau's, 66 
winder, 18 
Bandaging, 17 
rules for, 21 
Bartlett's catgut, preparation of, 

414 
Barton's bandage, 43 

modified, 43 
Bavarian dressing, 112 
Beck's bismuth emulsion, 303 
Bed sores, treatment of, 336 
Bellocq's cannula, 293 
Bichloride cotton, preparation of, 
•419 
gauze, preparation of, 417 
of mercury, sterilization by, 400 
Bier's hyperemic treatment, 196 
Binder's board splints, 120, 448 
Biniodide of mercury, sterilization 

by, 401 
B. I. P. P., sterilization by, 406 
Bis-axillary cravat, 36 
Black muslin bandage, 100 
Bladder, foreign bodies in, 362 
hemorrhage from, treatment of, 

295 
irrigation of, 251 
sterilization of, 426 
Blank-cartridge wounds, treat- 
ment of, 316 
Blastomyces, 393 
Blood, autotransfusion of, 157 
coagulation time of, 297 
serum in hemorrhages, 284 
transfusion of, 150 
arterial, 157 
autotransfusion, 157 
Brewer's method of, 154 
Crile's method of, 154 



Blood, transfusion of, donor in, 
152 
Hartwell's method of, 155 
Kimpton Brown's method of, 

156 
Lewisohn's sodium citrate 
method of, 155 
Bloodletting, 145 
Body of scapula, fracture of, 471 
Boiled catgut, preparation of, 412 
Boils, treatment of, 367 
Bond's splint, 489 
Bone transplantation in ununited 
fracture, 526 
Albee's method, 526 

chips, decalcified, 187 

forceps, 561 

grafting of, 185 

plates, decalcified, 187 

transplantation of, 185 

wax, 187 
Bones of leg, fractures of, ambula- 
tory treatment of, 516 
Boric acid, sterilization by, 408 
Boro-salicyhc powder, sterilization 

by, 408 
Borsch's eye bandage, 95 
Bougies, 244, 247 

esophageal, 174 

rectal, 175 

sterilization of, 244, 429 
Bovine lymph, 176 

virus, 176 
Brachial artery, ligation of, 609 

at bend of elbow, 609 
Bran bag in fractures, 449 
Breast, suspensory bandage of, 75 
Brewer's method of blood transfu- 
sion, 154 
Bromide of ethyl, anesthesia from, 

237 
Bronchi, foreign bodies in, 365 
Bronchoscopy, 193 
Brown's method of blood transfu- 
sion, 156 
Bruises, treatment of, 324 
Brush-burn, treatment of, 324 
Buried sutures, 258 
Burns, 325 

ambrine dressing in, 328 

carron oil in, 327 

contractures from, 331 

dichloramine-T dressing in, 329 

of epiglottis, 330 



INDEX 



629 



Burns of esophagus, 330 

of fingers, 331 

of glottis, 330 

of hands, 331 

horse serum in, 329 

paraffine dressing in, 328 

of pharynx, 330 

picric acid dressing in, 327 

powder, treatment of, 323 

roentgen-ray, treatment of, 335 

skin grafting for, 331 

of tongue, 330 

treatment of, 326 

ulcers and, 331 
scarlet red in, 331 

white-lead dressing in, 328 
Buttock, spica bandage of, 82 
Button sutures, 253, 263 
Button-hole suture, 260 



Calcaneum, dislocation of, 558 

fracture of, 518 
Calcium chloride in hemorrhages, 

283 _ 
Callosity, 571 
Callous ulcer, 373 
Cancrum oris, 356 
Cannula, Bellocq's, 293 
Cantharidial collodion as vesicant, 

141 
Cantharis, 141 
Capillary hemorrhage, treatment 

of, 291 
Capsicum as rubefacients, 140 
Capsine plaster, 141 
Carbolic acid, sterilization by, 401 
Carbolized gauze, preparation of, 

418 
Carbon dioxide in treatment of 

vascular growths, 272 
Carbonate of sodium in sterilizing 

hands, 428 
Carbuncle, 367 

treatment of, 369 
vaccine, 370 
Carotid artery, common, ligation 
of, 603 
external, ligation of, 604 
internal, ligation of, 605 
Carpal bones, dislocation of, 545 
fractures of, 492 



Carrel-Dakin treatment of wounds, 
317 
appliances required, 317 
material required, 317 

Carron oil in burns, 327 

Cartilages, semilunar, dislocation 
of, 555 

Catgut, Bartlett's, preparation of, 
414 
boiled, preparation of, 412 
chromic acid, preparation of, 413 
chromicized, preparation of, 413 
cumol, preparation of, 413 
drain, preparation of, 416 
formalin, preparation of, 412 
iodine, preparation of, 413 
ligatures, preparation of, 411 
sutures, preparation of, 411 
von Bergmann's, preparation of, 
412 

Catherization of ureters in males, 
191 

Catheters, 244 
flexible, 245 

French, 246 
introduction of, 248 
metallic, 245 
passing of female, 250 
prostatic, 246 
self -retaining, 251 
sterilization of, 244, 429 
tying of, in male bladder, 250 

Cauterization in hemorrhages, 285 

Cautery irons, 143 

C-E mixture, anesthesia from, 236 

Cellulitis, treatment of, 346 

Celluloid thread, preparation of, 
414 

Cephalic tetanus, 361 

Ceratum cantharides as vesicant, 
141 

Chain-stitch sutures, 260 

Chalk and gum splints, 448 

Chartse sinapis, 140 

Chauffeur's fracture, 491 

Chest, figure-of-eight bandage of, 73 
spiral bandage of, 73 
strapping of, 130 
T-bandage of, double, 31 
single, 28 

Chilblains, 332 

Chin, bandage of, four-tailed, 32 

Chlorazene, sterilization by, 406 

Chlorcosane, sterilization by, 405 



630 



INDEX 



Chloride of ethyl, anesthesia from, 
237 
of lime in sterilizing hands, 428 
of zinc, sterilization by, 407 
Chloroform, administration of, 234 
accidents during, 235 
cardiac syncope and, 236 
mechanical asphyxia and, 235 
preparation of patients for, 

233 
respiratory arrest and, 235 
and oxygen, anesthesia from, 236 
anesthesia from, 232 
as rubefacient, 140 
Chromic acid catgut, preparation 

of, 413 
Chromicized catgut, preparation 

of, 413 
Cigarette drain, preparation of, 416 
Circular bandage, 23 
Circumcision, 576 
Clavicle, dislocation of, 534 
acromial end, 535 
sternal end, 534 
fracture of, 465 
Clavus, treatment of, 572 
Closed fracture, 439 
Clothing of surgeons and assistants, 

sterilization of, 430 
Coagulation time of blood, 297 
Coaptation suture, 253 
Cocaine, anesthesia from, 210 
Coccyx, dislocation of, 532 

fracture of, 462 
Cold, anesthesia from, 209 
compresses, 137 
effects of, 332 
in hemorrhages, 282 
water dressings, 137 
Coley's fluid, 179 
Colles' fracture, 487 

reversed, 492 
Comminuted fracture, 439 
Common carotid artery, ligation of, 
603 
iliac artery, ligation of, 614 
Complete dislocation, 529, 559 

fracture, 437 
Complicated dislocation, 529 

fracture, 440 
Compound bandage, 27 
dislocation, 529, 559 
fracture, 439, 519 
Compresses, 125 



Compresses, cold, 137 
in fracture, 449 
in hemorrhage, 277 
hot dry, 133 

Compression, 195 

Congenital dislocations, 560 

Consecutive hemorrhage, treat- 
ment of, 292 

Contamination by bacteria, 382 

Continued suture, 258 

Continuous intratracheal insuffla- 
tion in artificial respiration, 170 

Contractures from burns, 331 

Contused wounds, treatment of, 
311 

Contusions, 324 
of joints, 337 
of scalp, 314 

Coracoid process of scapula, frac- 
ture of, 471 

Corns, treatment of, 572 

Coronoid process of ulna, frac- 
tures of, 484 

Costal cartilages, dislocation of, 
533 
fracture of, 461 

Cotton, 124 
absorbent, 124 
bandage, elastic, 121 
sterilized, 419 

Counter-irritation, 138 
Seguin's method of, 142 

Cradle in fracture, 450 

Creolin, sterilization by, 408 

Crile's method of blood transfusion, 
154 

Crossed bandage of eye, 52 

Cumol catgut, preparation of, 413 

Cupping, 146 
dry, 146 
wet, 147 

Curling ulcer, 326 

Cyst, sebaceous, treatment of, 572 

Cystoscope, 189 

Czerny-Lembert suture, 269 



Dakin's oil, sterilization by, 405 

pads, 410 

solution, sterilization by, 403, 
406 
Debridement of wounds, 320 



INDEX 



631 



Decalcified bone chips, 187 

plates, 187 
Decubitus, treatment of, 336 
Demi-gauntlet bandage, 58 
Desault's bandage, 68 
Diabetic gangrene, 354 
Dichloramine-T dressing in burns, 
329 
sterilization by, 405, 406 
Diffuse suppuration, treatment of, 

302 
Digital compression in hemorrhage, 

276 
Diphtheria bacillus, 391 
Diplococcus pneumoniae, 388 
Disinfection, mechanical, 396 

methods of, 396 
Dislocation or Dislocations, 529 
of ankle, 556 
of astragalus, 557 
of calcaneum, 558 
of carpal bones, 545 
of clavicle, 534 
acromial end, 535 
sternal end, 534 
of coccyx, 532 
complete, 529 
complicated, 529, 559 
compound, 529, 559 
congenital, 560 
of costal cartilages, 533 
of elbow, 541 . 
backward, 541 
forward, 543 
lateral, 542 
of femur, head of, 548 
anomalous, 553 
backward, 548 
downward, 550 
forward, 550, 552 
posterior, 548 
upward, 552 
of fibula, 556 
of fingers, 546 
habitual, 529, 560 
of hip, 548 
of humerus, 536 

head, subclavicular, 536 
subcoracoid, 536 
subglenoid, 536 
subspinous, 536 
of hyoid bone, 533 
of knee, 554 
of lower jaw, 532 



Dislocation of metacarpal bones, 
546 

of metatarsal bones, 558 

old, 530, 558 

partial, 529 

of patella, 554 

pathological, 560 

of pelvis, 534 

of phalanges of toes, 558 

of phalanx of thumb, 547 

of radius, head of, 543 

recent, 530 

of ribs, 533 

of scaphoid, 558 

of scapula, 536 
inferior angle, 536 

of semilunar cartilages, 555 

of shoulder, 536 

simple, 529 

of sternum, 533 

of tarsal bones, 557 

treatment of, 530 

of ulna, upper end of, 544 

of vertebrae, 531 

of wrist, 544 
Dorsalis pedis artery, ligation of, 

622 
Double ligatures, 271 

roller-bandage, 20 

T-bandage, 30 
Drainage tubes, preparation of, 414 
Dressing, Bavarian, 112 

cold water, 137 

fixed, 104 

of fractures, material and appli- 
ances used in, 447 
provisional, 444 

gauze, preparation of, 417 

plaster-of-Paris, 104 

surgical, 123 

of wounds, 308 
Dry cupping, 146 

gangrene, 350 

sterilized gauze dressing, prep- 
aration of, 420 

sterilization, 398 
Dupuytren's splint, 517 

E 

Ear, foreign bodies in, 367 
Edematous ulcer, 372 
Elastic constriction in hemorrhages, 
279 



632 



INDEX 



Elastic cotton bandage, 121 
ligatures, 273 
webbing bandage, 103 
Elbow, dislocation of, 541 
figure-of-eight bandage of, 62 
pulled, 544 
Electricity, injuries from, 333 
Electrolysis, 188 
Electrothermic mattress, 306 
Embolic gangrene, 354 
Embolism, air, treatment of, 347 
fat, treatment of, 347 
treatment of, 349 
Emposthotonos, 359 
Enemata, 175 
glycerin, 175 
nutritious, 175 
Enteroclysis, 161 
Epidural anesthesia, 215 
Epiglottis, burns of, 330 
Epinephrin, anesthesia from, 214 
Epiphyses, separation of, 452 
compound, 452 
simple, 452 
Epistaxis, 293 

Equisetene, preparation of, 411 
Erysipelas, 345 
symptoms of, 345 
treatment of, 346 
Esmarch's bandage and tube in 
hemorrhages, 280 
inhaler, 234 
Esophageal bougie, 174 
Esophagoscopy, 193 
Esophagus, burns of, 330 

foreign bodies in, 364 
Ether, administration of, 224 
accidents during, 226 
continuous drop method, 224 
failure of respiration during, 

227 
open drop method, 224 
spasmodic respiratory failure 

during, 228 
vomiting during, 226 
after-effects of, 228 
and nitrous oxide gas, anesthesia 

from, 230 
and oxygen, anesthesia from, 

230 
anesthesia from, 223 
first insensibility from, 226 
inhaler, Allis, 224 
rausch, 226 



Eucaine hydrochlorate, anesthesia 

from, 212 
Evaporating lotions in fracture, 

450 
Exploring needle, 182 

syringe, 172 

trocar, 182 
External carotid artery, ligation of , 
604 

iliac artery, ligation of, 615 
Extradural hemorrhage, 296 
Extremities, fractures of, trans- 
portation of, 445 
Extubation of larynx, 593 
Eye, bandage of, Borsch's, 95 
crossed, 52 
Liebreich's, 94 

foreign bodies in, 366 



Facial artery, ligation of, 606 
Faradization, 189 
Fascia, strains of, 341 
Fat embolism, treatment of, 347 
Feet, sterilization of, 425 
Felon, 580 
subcutaneous, 580 
subcuticular, 580 
suppurative, 581 
treatment of, 581 
Felt splints, 121, 448 
Femoral artery, ligation of, 618 

at apex of Scarpa's triangle, 

618 
below Poupart's ligament, 

618 
in Hunter's canal, 619 
in middle of thigh, 619 
hernia, Hood's truss for, 243 
trusses for, 243 
Femur, dislocation of head of, 548 
anomalous, 553 
backward, 548 
downward, 550 
forward, 550, 552 
posterior, 548 
upward, 548 
fracture of, 494 

ambulatory treatment of, 508 
lower end, 505 
shaft of, 498 
in children, 506 



INDEX 



633 



Femur, fracture of upper extrem- 
ity of, 494 
Fibula, dislocation of, 556 
fracture of, 516 

lower end, 517 
Figure-of-eight bandage, 26 

of chest, 73 

of elbow, 62 

of knee, 83 

of leg, 91 

of neck and axilla, 66 
Fingers, amputations of, 561, 562 

dressing of, 567 
burns of, 331 
dislocations of, 546 
spiral bandage of, 56 
reversed, 57 
Fissured fracture, 437 
Fistula, treatment of, 302 
Fixed dressings, 104 
Flannel bandage, 99 
Flat knots, 255 
Flavine, sterilization by, 405 
Flaxseed poultice, 132 
Flexible catheters, 245 
Fomentation, hot, 133 
Foot, bandage of, American, 87 

complete, 86 

French, 88 

spica, 86 
Foreign bodies in bladder, 362 

in bronchi, 365 

in ear, 367 

in esophagus, 364 

in eye, 366 

in intestines, 365 

in larynx, 365 

in nose, 366 

in penis, 363 

in pharynx, 364 

in rectum, 363 

removal of, 362 

in stomach, 365 

in trachea, 365 

in urethra, 362 

in vagina, 364 
Formaldehyde, sterilization by, 403 
Formalin catgut, preparation of, 

412 
sterilization by, 403 
Fracture or Fractures, 437 
of alveolar processes, 456 
of astragalus, 518 
bandages in, 449 



Fracture bed, 447 

of bones of leg, ambulatory 

treatment of, 516 
box, 449 
bran bag in, 449 
of calcaneum, 518 
of carpal bones, 492 
Chauffeur's, 491 
of clavicle, 465 

in children, 470 
closed, 439 
of coccyx, 462 
Colles', 487 

reversed, 492 
comminuted, 439 
complete, 437 
complicated, 440 
compound, 439, 519 
compresses in, 449 
of costal cartilages, 461 
cradle in, 450 
deformed union in, 527 
deformity and, 442 
dressing of, material and appli- 
ances used in, 447 

provisional, 444 
evaporating lotions in, 450 
of extremities, transportation of, 

445 
of femur, 494 

ambulatory treatment of, 508 

lower end, 505 

shaft, 498 

in children, 506 

upper extremity, 494 
of fibula, 516 

lower end, 517 
fissured, 437 
examination of, 442 

anesthetics in, 443 

roentgen ray in, 443 
green-stick, 437 
gunshot, 438 
of humerus, 472 

anatomical neck, 472 

head, 472 

lower extremity, 477 

shaft, 474 

surgical neck, 472 

upper epiphysis, 474 
extremity, 472 
of hyoid bone, 459 
of ilium, 462 
impacted, 440 



634 



INDEX 



Fracture, indented, 437 
of ischium, 462 
junk bag in, 449 
of larynx, 459 
longitudinal, 441 
of lower extremity, 494 

jaw, 457 
of malar bone, 455 
of metacarpal bones, 492 
of metatarsal bones, 519 
multiple, 439 
of nasal bone, 454 

processes, 456 
oblique, 440 
open, 439, 519 
partial, 437 
of patella, 508 
of pelvis, 462 
perforating, 437 
of phalanges of hand, 493 

of toes, 519 
Pott's, 517 
prognosis of, 441 
of pubis, 462 
punctured, 437 
rack in, 450 
of radius, head, 484 

lower end, 487 

neck, 484 
reduction of, 446 
repair of, 443 
of ribs, 460 
of sacrum, 462 
sand bag in, 449 
of scapula, 471 

acromion process, 471 

body, 471 

coracoid process, 471 

neck, 471 
setting of, 446 
simple, 439 

operative treatment of, 451 
of skull, 464 
splints in, 446 
of sternum, 461 
subperiosteal, 438 
symptoms of, 441 
of tarsal bones, 518 
of tibia, 511 

and fibula, 511 
of trachea, 459 
transverse, 440 
of ulna and radius, 485 
green-stick, 486 



Fracture, ulna and radius, incom- 
plete, 486 
coronoid process of, 484 
olecranon process of, 482 
shaft, 484 
ununited, 524 

bone transplantation in, 526 
Albee's method, 526 
of upper jaw, 456 
of vertebrae, 463 
of zygoma, 455 
French flexible catheters, 246 
Frost-bite, treatment of, 332 
Functional capacity of kidneys, 

estimation of, 192 
Furuncle, treatment of, 367 



G 



Galvano-cautery, 188 
Gangrene, 349 

acute, 352 

diabetic, 354 

dry, 350 

embolic, 354 

microbic, 353 

moist, 352 

presenile, 355 
Gangrenous stomatitis, 356 
Gas bacillus, 372 

poisoning, 162 
Gastroscopy, 193 
Gauntlet bandage, 57 
Gauze bandage, 96 

bichloride, preparation of, 417 

carbolized, preparation of, 418 

corrosive sublimate, preparation 
of, 417 

drain, preparation of, 415 

dressing, dry sterilized, 420 
moist sterilized, 419 
preparation of, 417 
resterilization of used, 421 

iodoform, preparation of, 418 

pads, 410 

paraffine, preparation of, 421 

sponges, sterilization of, 410 

sterilized, preparation of, 419 
Gelatin in hemorrhages, 283 
General anesthesia, 209, 218 
Germicidal solutions, 396 
Gibson's bandage, 46 
Glottis, burns of, 330 



INDEX 



635 



Gluteal artery, ligation of, 617 
Glycerin enemata, 175 

tampon, 125 
Golding-Bird's tracheal dilator, 584 
Gonococcus, 389 
Gowns, sterilization of, 419 
Grafting of bone, 185 

of muscles, 188 

of nerves, 188 

of skin, 182 
Granny knot, 257 
Green-stick fracture, 437 
Groin, spica bandage of, ascending, 
77 
descending, 79 
double, 80 
T-bandage of, 29 
Gunshot fracture, 438 

wounds, treatment of, 314 
Gutta-percha splints, 448 



H 



Habitual dislocation, 529, 560 
Halsted's mattress suture, 268 
Hand, amputation of, dressing of, 
567 
bandage of, complete, 59 
phalanges of, fracture of, 493 
Handkerchief bandage, 34 et seq. 
Hands, burns of , 331 

removal of plaster-of -Paris from, 

114 
sterilization of, 427 

carbonate of sodium in, 428 
chloride of lime in, 428 
Harrington's method, 428 
Hardening bandages, 104 
Hare-lip suture, 261 
Harrington's method of sterilizing 

hands, 428 
Hartwell's method of blood trans- 
fusion, 155 
Hatter's felt splints, 121 
Head and neck bandage, 51 
bandages of, 43 
four-tailed, 32 
oblique, 54 
recurrent, 48 

transverse, 50 
V, 50 
of femur, dislocation of, 548 
of humerus, dislocation of, 536 



Head of humerus, fracture of, 472 
of radius, dislocation of, 543 
fracture of, 484 

Healthy ulcer, 372 

Heat, sterilization by, 399 

Heel, bandage of, 88, 89 

Hemarthrosis, 337 

Hematoma, 292 

of scalp, treatment of, 314 

Hemolysis, 151 

Hemophilia, 296 

Hemorrhage, adrenalin chloride in, 
283 
antipyrin in, 283 
arterial, permanent control of, 
282 
temporary control of, 275 
arteriorrhaphy in, 287 
blood serum in, 284 
calcium chloride in, 283 
capillary, treatment of, 291 
cauterization in, 285 
cold in, 282 
compresses in, 277 
consecutive, treatment of, 292 
digital compression in, 276 
elastic constriction in, 279 
Esmarch's bandage and tube in, 

280 
extradural, 296 

from bladder, treatment of, 295 
from nose, treatment of, 293 
from prostate gland, treatment 

of, 295 
from urethra, treatment of, 294 
gelatin in, 283 
hemostatic forceps in, 280 
hot water in, 282 
intra-abdominal, 296 
of kidney, treatment of, 295 
ligature en masse in, 286 
ligatures in, 285 
position in, 282 
pressure in, 284 
reactionary, treatment of, 292 
of rectum, treatment of, 295 
secondary, treatment of, 292 
Spanish windlass in, 278 
of special parts, control of, 293 
of stomach, treatment of, 295 
styptics in, 282 

subcutaneous, treatment of, 292 
suture ligature in, 286 
torsion in, 285 



636 



INDEX 



Hemorrhage, tourniquets in, 277 
treatment of, 274 
venous, treatment of, 289 
Hemostatic forceps in hemor- 
rhages, 280 
Hernia, femoral, trusses for, 243 
inguinal, trusses for, 242 
irreducible, trusses for, 244 
umbilical, trusses for, 244 
Hilton's method of treatment of 

acute abscess, 300 
Hip dislocation of, 548 
Holocaine hydrochlorate, anesthe- 
sia from, 213 
Hood's truss for femoral hernia, 243 
Horse serum in burns, 329 
Horsehair drain, preparation of, 
416 
sutures, preparation of, 411 
Hot air, application of, 195 
sterilizer, 420 
dry compresses, 133 
fomentations, 133 
water in hemorrhages, 282 
as rubefacient, 139 
in treatment of vascular 
growths, 273 
Howard's method of artificial 

respiration, 165 
Humerus, dislocation of, 536 
head, subclavicular, 536 
subcoracoid, 536 
subglenoid, 536 
subspinous, 536 
fracture of, 472 

anatomical neck, 472 
head, 472 

lower extremity, 477 
shaft, 474 
surgical neck, 472 
upper epiphysis, 474 
extremity, 472 
Hydrocele, treatment of, 577 
Hydrochlorite, sterilization by, 

406 
Hyoid bone, dislocation of, 533 

fracture of, 459 
Hyperemia, active, 199 

passive, 199 
Hyperemic treatment, Bier's, 196 
Hyphomyces, 393 
Hypnotism, 240 
Hypodermic injections, 177 
Hypodermoclysis, 160 



Ice-bag irrigation, 138 
Ichthyol plaster, 127 

poultices, 134 
Iliac artery, common, ligation of 
614 
external, ligation of, 615 
internal, ligation of, 615 
Ilium, fracture of, 462 
Immediate irrigation, 135 
Immunity, 384 
Impacted fracture, 440 
Impaction of rectum, 363 
Improvised antiseptic dressings, 
418 

aseptic dressings, 418 
Incised wounds, treatment of, 308 
Indented fracture, 437 
Indolent ulcer, 373 
Infected wounds, antiseptic treat- 
ment of, 436 
Infection by bacteria, 382 
Inferior thyroid artery, ligation of, 

602 
Infiltration anesthesia, 214 

regional, 209 
Inflamed ulcer, 372 
Influenza bacillus, 390 
Infusion of saline solution into 

arteries, 160 
Inguinal hernia, trusses for, 242 
Injections for antitoxins, 178 

of arsphenamine, 181 

hypodermic, 177 

of mercury in syphilis, 180 

of salvarsan, 181 

urethral, 252 
Ingrown toenail, 578 
Innominate artery, ligation of, 599 
Instruments, sterilization of, 428 
Internal carotid artery, ligation of, 
605 

iliac artery, ligation of, 615 

mammary artery, ligation of, 602 

pudic artery, ligation of, 617 
Interosseous artery, ligation of, 

613 
Interrupted plaster-of-Paris dress- 
ing, 108 

suture, 257 
Intestinal sutures, 267 
Intestines, foreign bodies in, 365 
Intra-abdominal hemorrhage, 296 



INDEX 



637 



Intratracheal insufflation anesthe- 
sia, 229 
in artificial respiration, 170 
Intravenous infusion of saline solu- 
tion, 157 
Intubation of larynx, 589 
feeding after, 595 
operation of, 596 
tube and introducer, 590 
extractor, 591 
scale of, 591 
Iodine catgut, preparation of, 413 

sterilization by, 403 
Iodoform gauze, preparation of, 
418 
sterilization by, 402 
Irreducible hernia, trusses for, 244 
Irrigation, 134 
of bladder, 251 
cold water dressings, 137 
ice-bag, 138 
immediate, 135 
mediate, 136 
Irritable ulcer, 373 
Ischium, fracture of, 462 
Isinglass plaster, 128 



Jaw, lower, fracture of, 457 

lumpy 393 

oblique bandage of, 47 

upper, fracture of, 456 
Joints, contusion of, 337 

injuries of, 337 

sprains of, 337 

strapping of, 131 

wounds of, 338 
Junk bag in fracture, 449 
Jury mast, application of, 111 



K 



Kangaroo tendon sutures, prep- 
aration of, 414 

Kelene, anesthesia from, 237 

Kidney, hemorrhage of, treatment 
of, 295 

Kidneys, functional capacity of, 
estimation of, 192 

Knee, dislocation of, 554 

figure-of-eight bandage of, 83 



Knots, flat, 255 

granny, 257 

reef 255 

Staffordshire, 257 

surgeon's, 256 
Kocher's method in dislocation of 

humerus, 538 



Laborde's method of artificial 

respiration, 168 
Lacerated wounds, treatment of, 

309 
Lane's plates, 520 
Laryngoscopy, 193 
Laryngotomy, 588 
Laryngo-tracheotomy, 589 
Larynx, extubation of, 593 
foreign bodies in, 365 
fracture of, 459 
intubation of, 589 
feeding after, 595 
operation of, 591 
Lavage, 173 

Lead water and laudanum poul- 
tices, 134 
Leather splints, 119 

undressed, splints of, 448 
Leeching, 148 

mechanical, 148 
Leg, bones of, fractures of, ambu- 
latory treatment of, 516 
figure-of-eight bandage of, 91 
splint, Thomas' traction, 501 
Lembert's suture, 267 
Leukocytosis, 386 
Levis' apparatus for dislocation of 

phalanges of hand, 547 
Lewisohn's sodium citrate method 

of blood transfusion, 155 
Ligation of arteries, 597 
abdominal aorta, 613 
anterior tibial, 620 

at its middle third, 621 
in its lower third, 622 
in upper third of leg, 621 
axillary, 607 
in axilla, 608 
below clavicle, 607 
brachial, 609 

at bend of elbow, 609 
common carotid, 603 



638 



INDEX 



Ligation of arteries, common iliac, 
614 
dorsalis pedis, 622 
external carotid, 604 

iliac, 615 
facial, 606 
femoral, 618 

at apex of Scarpa's triangle, 

618 
below Poupart's ligament, 

618 
in Hunter's canal, 619 
in middle of thigh, 619 
gluteal, 617 
inferior thyroid, 602 
innominate, 599 
internal carotid, 605 
iliac, 615 
mammary, 602 
pudic, 617 
interosseous, 613 
lingual, 605 
occipital, 606 
popliteal, 620 
posterior tibial, 622 

at its middle third, 624 
at its upper third, 622 
behind inner malleolus, 
624 
radial, 610 

at root of thumb, 612 

in lower third of forearm, 

612 
in middle third of forearm, 

611 
in upper third of forearm, 
610 
sciatic, 617 
subclavian, 600 
superior thyroid, 605 
temporal, 607 
ulnar, 612 

at junction of upper and 
middle thirds of forearm, 
612 
in lower third of forearm, 
612 
vertebral, 602 
wounded, rules for, 289 
Ligature en masse in hemorrhages, 

286 
Ligatures, catgut, 411 
double, 271 
elastic, 273 



Ligatures in hemorrhages, 285 

method of securing, 255 

quadruple, 271 

silk, 410 

single, with pin, 270 

subcutaneous, 272 

in treatment of vascular growths, 
270 
Lightning stroke, treatment of, 335 
Lingual artery, ligation of, 605 
Lint, 123 
Lipemia, 347 
Lipuria, 347 

Lithotomy, bandage for, 94 
Local anesthesia, 208, 209 
Lockjaw, 392 
Longitudinal fracture, 441 
Lower extremity, bandage of, 77 
spiral reversed, 89 
fractures of, 494 

jaw, dislocation of, 532 
Lumbar puncture, 575 
Lumpy jaw, 393 

Lung motor in artificial respira- 
tion, 169 
Lymph, bovine, 176 



M 



McBtjkney's hook, 184 

Magnesium sulphate solution poul- 
tices, 134* 

Malar bone, fracture of, 455 

Mammary artery, internal, liga- 
tion of, 602 

Many-tailed bandages, 31 
of abdomen, 32 

Margolin, ulcer of, 378 

Massage, 194 

Mattress suture, 261 

Mechanical disinfection, 396 
leeching, 148 
sterilization, 396 

Mediate irrigation, 136 

Mercurochrome, sterilization by, 
406 

Mercury, injections of, in syphilis, 
180 

Metacarpal bones, amputation of, 
561, 564 
dislocation of, 546 
fractures of, 492 

Metallic catheters, 245 



INDEX 



639 



Metatarsal bones, amputation of, 
570 
all the metatarsal bones, 570 
fifth, 570 
dislocation of, 558 
fractures of, 519 
Microbic gangrene, 353 
Mikulicz bag, 416 
pack, 403 
tampon, 416 
Moist gangrene, 352 

sterilized gauze dressings, 419 
Morphine anesthesia, 238 
Mothe's method in dislocation of 

humerus, 538 
Moulded plaster-of -Paris splints, 
113 
splints, 119 
Moulds, 393 
Mouth gag, 590 

sterilization of, 427 
Multiple fracture, 439 
Muscle, grafting of, 188 

strains of, 341 
Muslin, oiled, 124 
Mustard papers as rubefacient, 140 
plaster, 140 
as rubefacient, 140 



N 



Nares, plugging of, 294 
Nasal bone, fracture of, 454 

cavities, sterilization of, 427 

processes, fracture of, 456 
Neck of radius, fracture of, 484 

of scapula, fracture of, 471 
Necrosis, 349 
Needle, aneurysm, 598 

exploring, 182 

surgical, 254 
Nerve, grafting of, 188 

suture, 266 
Nitrous oxide and oxygen, anes- 
thesia from, 222 
gas, anesthesia from, 221 
Noma, 356 
Nose, foreign bodies in, 366 

hemorrhage of, treatment of, 293 

T-bandage of, 31 
Novocaine, anesthesia from, 212 
Nutritious enemata, 175 



Oakum, 123 

Oblique bandage, 23 
of head, 54 
of jaw, 47 
fracture, 440 

Occipital artery, ligation of, 606 

Occipito-facial bandage, 54 

Occipito-frontal bandage, 55 

Oil-ether, anesthesia from, 231 

Oiled muslin, 124 
silk, 124 

Old dislocation, 530, 558 

Olecronon process of ulna, frac- 
ture of, 482 

Open fracture, 439, 519 

Operating suits, sterilization of, 419 

Opisthotonos, 359 

Opsonic treatment, 385 



Pads, Dakin's, 410 

gauge, 410 
Palmar abscess, treatment of, 582 
Panelectroscope, 191 
Paper lint, 123 

splints, 448 
Papilloma, 571 

Paquelin's thermo-cautery, 144 
Paracentesis abdominalis, 573 

pericardii, 574 

thoracis, 573 

vesicae, 575 
Parafnne bandage, 119 

dressing in burns, 328 

gauze, preparation of, 421 

paper, 124 
Paralysis, postanesthetic, 239 
Parasacral anesthesia, 216 
Parchment-paper, 125 
Paronychia, treatment of, 580 
Partial dislocation, 529 

fracture, 437 
Passive motion, 195 
Pasteboard splints, 120 
Patella, dislocation of, 554 

fracture of, 508 
Pathogenic action of bacteria, 382 
Pathological dislocations, 560 
Pelvic supporter, 107 
Pelvis, dislocation of, 534 



640 



INDEX 



Pelvis, foreign bodies in, 363 

fracture of, 462 
Penis, spiral reversed bandage of, 

92 
Perforating fracture, 437 
Perineum, T-bandage of, 83, 92 
Permanganate of potassium, steril- 
ization by, 409 
Pernio, 332 
Peroxide of hydrogen, sterilization 

by 407 
Petit's tourniquet, 277 
Phagocytosis, 385 
Phalanges of hand, fracture of, 493 
of toes, dislocation of, 558 
fractures of, 519 
Phalanx of thumb, dislocation of, 

547 
Pharyngeal insufflation anesthesia, 

228 
Pharynx, burns of, 330 
foreign bodies in, 364 
Phlelorrhaphy, 290 
Physiological shock, 304 
Picric acid dressing in burns, 327 

sterilization by, 403 
Plaster or Plasters, 127 
capsine, 141 
ichthyol, 127 
isinglass, 128 
mustard, 140 

-of -Paris bandage, application of, 
106 
preparation of, 105 
removal of, 115 
saw for, 116 
shears for, 117 
trapping of, 114 
dressings, 104 

interrupted, 108 
jacket, application of, 109 
removal of, from hands, 114 
splints, 448 
resin, 127 

rubber adhesive, 127 
soap, 128 
spice, 141 

splints, moulded, 113 
swans' down, 127 
tape, closure of arteries by, 288 
zinc oxide, adhesive, 128 
sterile, 128 
Plate sutures, 253, 263 
Pleurothotonos, 359 



Poisoned wound, treatment of, 312 
Poisoning, gas, 162 
Popliteal artery, ligation of, 620 
Postanesthetic paralysis, 239 
Posterior tibial artery, ligation of, 
. 622 
at its middle third, 624 
at its upper third, 622 
behind inner malleolus, 
624 
Postoperative treatment, 432 
Potain's aspirator, 170, 171 
Pott's fracture, 517 
Poultices, 131 

antiseptic, 133 

fermenting, 133 

flaxseed, 132 

ichthyol, 134 

lead water and laudanum, 134 

magnesium sulphate solution, 
• 134 

soap, 132 

starch, 132 
Powder burns, treatment of, 323 
Presenile gangrene, 355 
Procaine as local anesthetic, 213 
Prone method of artificial respira- 
tion, 169 
Prostate gland, hemorrhage from, 

treatment of, 295 
Prostatic catheters, 246 
Protargol, sterilization by, 407 
Protective, preparation of, 416 
Protozoa, 394 
Pubis, fracture of, 462 
Pudic artery, internal, ligation of, 

617 
Pulled elbow, 544 
Pulmotor in artificial respiration, 

169 
Puncturation, 146 
Punctured fracture, 437 

wounds, treatment of, 311 
Purse-string suture, 268 
Putrefactive bacteria, 393 
Pyemia, treatment of, 344 
Pyogenic bacteria, 387 



Quadriceps extensor tendon, rup- 
ture of, 511 
Quadruple ligature, 271 



INDEX 



641 



Quilled sutures, 253, 261 
Quilt suture, 261 

Quinine-urea hydrochloride, anes- 
thesia from, 213 



R 



Rack in fracture, 450 
Radial artery, ligation of, 610 

in lower third of forearm, 

612 
in middle third of forearm, 

611 
at root of thumb, 612 
in upper third of forearm, 
610 
Radium therapy, 205 
Radius, head of, dislocation of, 543 
fracture of, 484 
lower end of, fracture of, 487 
neck of, fracture of, 484 
Ransohoff's tongs, 501 
Raw-hide splints, 119 
Reactionary hemorrhage, treat- 
ment of, 292 
Recent dislocation, 530 
Rectal bougies, 175 

tube, 174 
Rectum, foreign bodies in, 363 
hemorrhage of, treatment of, 295 
impaction of, 363 
sterilization of, 426 
Recurrent bandage, 27 
of head, 48 
of stump, 92 
Redressing of wounds, 433, 435 
Reduction of fractures, 446 
Reef knots, 255 
Regional infiltration, 209 
Relaxation, sutures of, 253 
Repair of fractures, 443 
Resin plaster, 127 
Respiration, artificial, 164 
Howard's method of, 165 
Laborde's method of, 168 
lung motor in, 169 
prone method of, 169 
pulmotor in, 169 
Schafer's method of, 169 
Silvester's method of, 167 
Resterilization of used gauze dress- 
~ ing, 421 
Retractors, 126 
41 



Reverdin's method of skin grafting, 

183 
Reversed Colles' fracture, 492 
Rhigolene, anesthesia from, 210 
Ribs, dislocation of, 533 

fracture of, 460 
Roentgen rays, 199 

burns, treatment of, 335 
examination of fractures, 443 
therapy, 202 
Roller bandage, 18 
Rubber adhesive plaster, 127 

bandage, 101 

dam, preparation of, 417 

gloves, sterilization of, 430 

tissue, 125 

preparation of, 417 
Rubefacients, 139 

aqua ammonia as, 141 

capsicum as, 140 

chloroform as, 140 

hot water as, 139 

mustard as, 140 
papers as, 140 

spirit of turpentine as, 139 

tincture of iodine as, 139 

turpentine stupe as, 139 
Rupture of quadriceps extensor 

tendon, 511 



Sacral, anesthesia, 215 
Sacrum, fracture of, 462 
Salicylic acid, sterilization by, 408 
Saline solution, infusion of, into 
arteries, 160 
intravenous infusion of, 157 
sterilization by, 409 
Salvarsan, injections of, 181 
Sand bag in fracture, 449 

bags, 126 

pillow, 126 
Sapremia, treatment of, 344 
Saws for removal of plaster-of- 

Paris bandages, 116 
Sayre's dressing in fracture of 

clavicle, 467 
Scalds, 325 

treatment of, 326 
Scalp, contusions of, treatment of, 
314 

hematoma of, treatment of, 314 



642 



INDEX 



Scalp, sterilization of, 427 

wounds, treatment of, 314 
Scalpel, 561 

Scaphoid, dislocation of, 558 
Scapula, acromion process of, frac- 
ture of, 471 

body of, fracture of, 471 

coracoid process of, fracture of, 
471 

dislocation of, 536 

fracture of, 471 

neck of, fracture of, 471 
Scarification, 145 

Schafer's method of artificial res- 
piration, 169 
Schede's operations for varicose 

veins, 371 
Sciatic artery, ligation of, 617 
Scopolamine, anesthesia from, 238 
Scultetus, bandage of, 95 
Sebaceous cyst, treatment of, 572 
Secondary hemorrhage, treatment 
of, 292 

sutures, 254 
Seguin's method of counter-irrita- 
tion, 142 
Self -retaining catheters, 251 
Semilunar cartilages, dislocation 

of, 555 
Sepsis, 395 

agents employed to secure, 399 

treatment of, 343 
Septicemia, treatment of, 343 
Setting of fractures, 446 
Shaft of femur, fracture of, in 
children, 506 

of humerus, fracture of, 472 

of ulna, fracture of, 484 
Shears for removal of plaster-of- 

Paris bandage, 117 
Shock, 304 

diagnosis of, 305 

physiological, 304 

prophylaxis in, 306 

symptoms of, 305 

treatment of, 307 
Shotted suture, 264 
Shoulder, dislocation of, 536 

spica bandage of, ascending, 63 
descending, 65 
Silicate of potassium bandage, 
118 
splints, 448 

of sodium bandage, 118 



Silk ligatures, preparation of, 410 
oiled, 124 

suture, sterilization of, 410 
Silkworm gut, preparation of, 411 
Silver foil, preparation of, 417 
nitrate, sterilization by, 406 
tracheotomy tube, 585 

with fenestrated guide, 585 

wire sutures, preparation of, 411 

Silvester's method of artificial 

respiration, 167 
Simple dislocation, 529 
fracture, 439 
ulcer, 372 
Sinapis alba, 140 

nigra, 140 
Sinus, treatment of, 302 
Skiagraphy, 199 
Skin grafting of, 182 
for burns, 331 
Reverdin's method of, 183 
Thiersch's method of, 184 
Wolfe-Krause's method of, 185 
Skull, fracture of, 464 
Slings, 31 

Smoke asphyxia, 163 
Soap plaster, 128 

poultice, 132 
Sodium chloride, sterilization by, 
409 
splints, 448. 
Solutions, germicidal, 396 
Sounds, 247, 248 
passing of, 247 
Spanish fly, 141 

windlass in hemorrhages, 278 
Spica bandage, 26 
of buttock, 82 
of foot, 86 

of groin, ascending, 77 
descending, 79 
double, 80 
single, 77 
of shoulder, ascending, 63 

descending, 65 
of thumb, 60 
Spice plaster, 141 
Spinal anesthesia, 216 
Spiral bandage, 23 
of chest, 73 
of finger, 56 
reversed bandage, 24 
of arm, 60 
of fingers, 57 



INDEX 



043 



Spiral reversed bandage of lower 
extremity, 89 
of penis, 92 
of thigh, 90 
of upper extremity, 61 
Spirit of turpentine as rubefacient, 

139 
Splints or Splints, 447 

Agnew's, for fracture of meta- 
carpal bones, 492 
of patella, 509 

arm, Thomas', 501 

binders' board, 120, 44S 

Bond's, 489 

chalk and gum, 448 

Dupuvtren's 517 

felt, 121, 448 

gutta-percha, 448 

hatter's felt, 121 

leather, 119 

leg, Thomas' traction, 501 

moulded, 119 

paper, 448 

pasteboard, 120 

plaster-of-Paris, 448 
moulded, 113 

raw-hide, 119 

silicate of potassium, 448 

sodium, 448 

starch, 448 

suture, 264 

Thomas, suspension in abduc- 
tion, 502 

undressed leather, 44S 

wooden, 447 
Sponges, gauze, sterilization of, 410 
Sprain-fracture, 338, 341 
Sprains of joints, 337 
Stab wounds, treatment of, 312 
Staffordshire knot, 257 
Staphylococcus aureus, 387 
Starch poultice, 132 

splints, 448 
Starched bandage, 117 
Sterilization, 396 

by acetanilide, 407 

by acetate of aluminum, 407 

antiseptic method of, 397 

by argyrol, 400 

by aristol, 409 

aseptic method of, 398 

of bandages, 419 

by bichloride of mercury, 400 

by biniodide of mercury, 401 



Sterilization by B. I. P. P., 406 

of bladder, 426 

by boric acid, 408 

by boro-salicylic powder, 408 

of bougies, 244, 429 

bv carbolic acid, 401 

of catheters, 244, 429 

by chlorazenc, 406 

by chlorcosane, 405 

by chloride of zinc, 407 

of clothing of surgeons and assist- 
ants, 430 

by creolin, 408 

by Dakin's oil, 405 
solution, 403, 406 

by dichloramine-T, 405, 406 

dry, 398 

of feet, 425 

by flavine, 405 

by formaldehyde, 403 

by formalin, 403 

of gauze pads, 410 
sponges, 410 

of gowns, 419 

of hands, 427 

by heat, 399 

by hychlorite, 406 

of instruments, 428 

by iodine, 403 

by iodoform, 402 

mechanical, 396 

by mercurochrome, 406 

of mouth, 427 

of nasal cavities, 427 

of operating suits, 419 

by permanganate of potassium, 
409 

bv peroxide of hydrogen, 
~407 

by picric acid, 403 

by protargol, 407 

of rectum, 430 

of rubber gloves, 430 

by salicylic acid, 408 

by saline solution, 409 

of scalp, 427 

of silk suture, 410 

by silver nitrate, 406 

by sodium chloride, 409 

of stomach, 426 

of towels, 419 

of urethra, 426 

of vagina, 426 

of water, 409 



Oil 



INDEX 



Sterilized cotton, preparation of, 
419 

gauze, preparation of, 419 
dressing, dry, preparation of, 
420 
moist, preparation of, 419 
Sterilizer, hot-air, 420 
Sternal end of clavicle, dislocation 

of, 534 
Sternum, dislocation of, 583 

fracture of, 461 
Stomach, foreign bodies in, 365 

hemorrhage of, treatment of, 
295 

sterilization of, 426 
Stomach-pump, 178 
Stomach-tube, 172 
Stomatitis, gangrenous, 350 
Stovaine hydrochloride, anesthesia 

from, 213 
Strains of fascia, 341 

of muscles, 341 
Strangury, 142 
Strapping, 129 

of back, 131 

of chest, 130 

of joints, 131 

of testicle, 129 

of ulcers, 130, 375, 376 
Streptococcus pyogenes, 388 
Stump, recurrent bandage of, 92 
Styptics in hemorrhages, 282 
Subarachnoid anesthesia, 216 
Subclavian artery, ligation of, 

600 
Subclavicular dislocation of head of 

humerus, 536 
Subcoracoid dislocation of head of 

humerus, 536 
Subcutaneous felon, 580 

hemorrhage, treatment of, 292 

ligature, 272 
Subcuticular felon, 580 

suture, 260 
Subglenoid dislocation of head of 

humerus, 536 
Subperiosteal fracture, 438 
Subspinous dislocation of head of 

humerus, 536 
Sulphuric ether, anesthesia from, 

210 
Sunburn, treatment of, 324 
Superior thyroid artery, ligation of, 

605 



Suppuration, bacteria of, 387 

diffuse, treatment of, 302 
Suppurative felon, 581 
Suprarenin, anesthesia from, 214 
Surgeon's knots, 256 
Surgical bacteriology, 379 

dressings, 123 

neck of humerus, fracture of, 
472 

needles, 254 
Suspension traction treatment of 

long bones near joints, 500 
Suture of arteries, 287 

ligature in hemorrhages, 286 

of veins, 290 
Sutures, 253 

Albert-Lembert, 269 

of approximation, 254 

buried, 258 

button, 253, 263 

button-hole, 260 

catgut, 411 

chain-stitch, 260 

of coaptation, 253 

continued, 258 

Czerny-Lembert, 269 

Halsted's mattress, 268 

hare-lip, 261 

horsehair, 411 

interrupted, 254 

intestinal, 267 

kangaroo tendon, 414 

Lembert's, 267 

mattress, 261 
continuous, 261 

method of securing, 255 

nerve, 266 

plate, 253, 263 

purse-string, 268 

quilled, 253, 261 

quilt, 261 

of relaxation, 253 

removal of, 265 

secondary, 254 

shotted, 264 

silk, sterilization of, 410 

silver wire, 411 

splint, 264 , 

subcuticular, 260 

tendon, 267 

twisted, 261 
Swans'-down plaster, 127 
Syphilitic ulcers, 378 
Syringe, exploring, 172 



INDEX 



645 



Tampon, 125 

glycerin, 125 
Tarsal bones, dislocation of, 557 

fractures of, 51 S 
T-bandage, 28 
of chest, 31 
double, 31 
single, 28 
double, 30 
of nose, 31 
of perineum, S3 
single, 28 
Temporal artery, ligation of, 607 
Tendon sutures, 267 

kangaroo, preparation of, 144 
Tent, 125 

Terminal anesthesia, 209, 214 
Testicle, strapping of, 129 
Tetanus, 357 
bacillus, 391 
cephalic, 361 
chronic, 362 
Thermo-cautery, Paquelin's, 144 
Thiersch's method of skin grafting, 

184 
Thigh, spiral reversed bandage of, 

90 
Thomas' arm splint, 501 

splint, half-ring modification of, 
for transport of fractures of 
lower extremity, 446 
hinged, for transport of frac- 
tures, 446 
suspension in abduction, 502 
traction leg splint, 501 
Thrombosis, treatment of, 348 
Thumb, dislocation of phalanx of, 
547 
spica bandage of, 60 
Thyroid artery, inferior, ligation 
of, 602 
superior, ligation of, 605 
Tibia and fibula, fractures of, 511 

fractures of, 511 
Tibial artery, anterior, ligation of, 
620 
at its middle third, 621 
in its lower third, 622 
in upper third of leg, 621 
posterior, ligation of, 622 
at its middle third, 624 
at its upper third, 622 



Tibial artery, posterior, ligation 

of, behind inner malleolus, 624 
Tincture of iodine as rubefacient, 

139 
Tissues, molecular death of, 349 
Toenail, ingrown, 578 
Toes, amputation of, 567 
all the toes, 569 
great, 569 

with its metatarsal bone, 
569 
two adjoining toes, 56S 
little, 570 
phalanges of, dislocation of, 
558 
fractures of, 519 
Tongue, burns of, 330 
Torsion in hemorrhages, 285 
Tourniquets in hemorrhage, 277 

Petit's, 277 
Towels, sterilization of, 419 
Trachea, foreign bodies in, 365 

fracture of, 459 
Tracheal dilators, 583 

forceps, 584 
Tracheotomy, 582 
operation of, 586 

high, 586 
position of patient for, 585 
tube, 585 
Traction leg splint, Thomas', 501 
Transfusion of blood, 150 
Transplantation of bone, 185 
in ununited fracture, 526 
Albee's method, 526 
Transportation of fractures of 

extremities, 445 
Transverse fracture, 440 

recurrent bandage of head, 50 
Trendelenburg's operations for 

varicose veins, 371 
Treponema pallidum, 392 
Trismus, 358 
Trocar, exploring, 182 
Trousseau's tracheal dilator, 584 
Trunk, bandages of, 73 
Truss, Hood's, 243 

worsted, 242 
Trusses, 240 

for femoral hernia, 243 
for inguinal hernia, 242 
for irreducible hernia, 244 
for umbilical hernia, 244 
Tuberculosis, bacillus of, 389 



046 



TXDEX 



Tuberculous abscess, treatment of. 

300 
aspiration in, 301 
incision in, 302 
injection in, 301 
puncture in, 301 
Turpentine stupe as rubefacient, 

139 
Twisted suture, 26] 



U 

Ulcers, 371 
callous, 373 
curling, 326 
edematous, 372 
healthy. 372 
indolent. 373 
inflamed, 372 
irritable, 373 
of Margolin, 37S 
simple. 372 

strapping of, 130, 37"), 370 
syphilitic, 37S 
varicose, 377 
warty, 378 
weak, 372 
Ulna and radius, fractures of, 485 
coronoid process of, fracture of, 

484 
dislocation of upper end of, 544 
olecranon process of, fracture of. 
482 
green-stick, 486 
incomplete, 480 
shaft of, fracture of, 484 
Ulnar artery, ligation of, 612 

at junction of forearm, 612 
in lower third of forearm, 
612 
Umbilical hernia, trusses for, 244 
Ununited fracture, 524 

bone transplantation in, 526 
. Albee's method, 520 
Upper extremity, bandages of, 50 

spiral reversed, 01 
Ureters in males, catheterization 

of, 191 
Urethra, foreign bodies in, 362 
hemorrhage from, treatment of, 

294 
sterilization of, 420 
Urethral injections, 252 
Urethroscope, 191 ' 



Vaccination, 176 
Vaccine, autogenous, 342 
bacterial, 3S5 
therapy, 342 
Vagina, foreign bodies in, 364 

sterilization of, 426 
Varicocele, operation for, 577 
Varicose ulcer, 377 
veins, 370 
Schede's operation for, 371 
Trendelenburg's operation for. 
371 
Vascular growths, treatment of, 
carbon dioxide in, 272 
hot water in, 273 
ligatures used in, 270 
V-bandage of head, 50 
Velpeau's bandage, 06 

dressing in fracture of clavicle, 
40S 
modified, in fracture of clavicle 
469 
Venereal warts, 571 
Venesection, 148 
Venous hemorrhage, treatment of, 

289. 
Verruca, 571 
Vertebra^, dislocation of, 531 

fracture of, 463 
Vertebral artery, ligation of, 602 
Vesicants, 141 

cantharidial collodion as, 141 
ceratum cantharides as, 141 
Veins, suture of, 290 
varicose, 370 

Schede's operation for, 371 
Trendelenburg's operation for, 
371 
Virus, bovine, 176 
Von Bergmann's catgut, prepara- 
tion of, 412 



W 

Warts, 571 

venereal, 571 
Warty ulcer, 378 
Wassermann test, 179 
Water sterilization of, 409 
Wax, bone, 187 
Waxed paper, 124 



INDEX 



647 



Weak ulcer, 372 

Wen, treatment of, 572 

Wet cupping, 147 

Wharton's tracheotomy director, 

583 
White-lead dressing in burns, 328 
Whitlow, treatment of, 580 
Wolfe-Krause's method of skin 

grafting, 185 
Wooden splints, 447 
Wood-wool, 124 
Worsted truss, 242 
Wounded arteries, ligation of, rules 

for, 289 
Wounds, asepsis in treatment of, 
dressings employed, 421 
methods employed, 421 
drying and chemical ster- 
ilization, 422 
moist dressing, 422 

modified, 422 
simple drying, 421 
blank-cartridge, treatment of, 

316 
Carrel-Dakin treatment of, 317 
contused, treatment of, 311 
debridement of, 320 
diseases complicating, 343 



Wounds, dressing of, 308 
gunshot, treatment of, 314 
incised, treatment of, 308 
infected, treatment of, 436 
of joints, 338 

lacerated, treatment of, 309 
poisoned, treatment of, 312 
punctured, treatment of, 311 
redressing of, 433, 435 
scalp, treatment of, 314 
stab, treatment of, 312 

Wrist, dislocation of, 544 



X 



Xeroform, sterilization by, 409 
X-rays, 199 



Yeasts, 393 



Zinc oxide adhesive plaster, 128 
Zygoma, fracture of, 455 



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